“Fourteen years of working non-stop as Bhutan’s first trained psychiatrist, often under very difficult circumstances and with poor or no support, has affected me personally. I feel emotionally drained and professionally burnt out.” Dr. Chencho Dorji

THIMPHU, BHUTAN—High in the Himalayas, in a happy kingdom known as “The Land of the Thunder Dragon,” a brilliant young monk once played with the children of his tiny village.

He picked the children up and chased them around the village chortens , the white stone monuments of Buddhist worship that dot the country’s verdant slopes. Sometimes, he played them songs on his bamboo flute.

But one day, he did something he had never done before.

The violence came without warning and the children screamed as they fled from his fists. The monk had gone mad and his family locked him up.

Spirits and deities were blamed. Rituals were performed. Offerings were made. No cure could be found.

But many years later, the monk’s brother unearthed the secret behind the madness. It was a word that had never been spoken before in his village.

Schizophrenia.

Toward modernity

When the monk was born 58 years ago, Bhutan was just about to begin its journey through time.

Bhutan in 1955 was still essentially medieval — a barter society without paved roads or electricity. For centuries, the hermit kingdom clung to isolation, nestled in the Himalayan folds of China and India.

But in the early ’60s, Bhutan’s king decided to crack open the kingdom doors. His tiny country was sent hurtling toward modernity.

Today, honking horns join the chimes of prayer wheels and crimson-robed monks text on their cellphones, which were only introduced in 2003. Many Bhutanese still wear the same clothes worn since the 17th century, but on a recent summer night one popular bar fills with miniskirts, T-shirts and acoustic Nirvana covers. There is no sign of the gho — the patterned kimono-like robe worn by men — and only one woman wears the intricately woven kira , her stiletto shoes sparkling beneath the ankle-length hem.

With Bhutan no longer off-limits to the world, tourism has become significant, bringing in nearly $48 million (U.S.) in 2011. Foreigners flock to see the world’s “last Shangri-La,” a land of gleaming rice paddies and rugged mountain peaks. They also want a taste of Bhutan’s famous brand of happiness.

In 1972, the country’s fourth king coined the phrase that has come to define Bhutan. “Gross national happiness,” he declared, is more important than gross domestic product.

Today, every policy proposal in Bhutan is screened by the Gross National Happiness Commission, and happiness is measured with surveys and indicators — everything from spirituality and sleeping hours to environmental responsibility.

Bhutan is widely considered a development success. Businessweek magazine in 2006 ranked Bhutan the eighth happiest country in the world. The United Nations recently commissioned the first World Happiness Report , which praised the tiny kingdom’s leadership.

“Bhutan is on to something path-breaking and deeply insightful,” the report said. “And the world is increasingly taking notice.”

But Bhutan is no Shangri-La. It is low-middle income and foreign debts are mounting. The country still draws criticism for expelling some 100,000 ethnic Nepalese in the ’90s, decried as an attempt to suppress Bhutan’s largest minority.

And, in the land of the happy, mental disorders are on the rise. Opening the kingdom doors has led to longer lives and rapid economic growth, but other forces have crept in, too — drugs, rapid urbanization and youth unemployment.

Since 1999, more than 5,300 depressed, anxious, psychotic and drug-addled Bhutanese have turned up at the country’s only psychiatric department — and the burden of treating them has largely fallen to one man.

His name is Dr. Chencho Dorji and he is Bhutan’s first psychiatrist. Four decades ago, his first patient began to lose his mind.

‘Pressure of ideas’

Chencho was always close with his brother Damchoy, the eldest of eight children born to a subsistence farmer and his two wives. But even as a young boy, he sensed something different about his handsome and intelligent sibling.

“He had so many things in his head that I couldn’t even imagine,” Chencho recalls. “I used to feel overwhelmed by the flight of his ideas, by the pressure of ideas in his head. I had difficulty trying to judge for myself whether I was normal or he was normal.”

Like everyone else in their village, Chencho believed his brother was destined to become one of Bhutan’s revered Buddhist monks. Damchoy joined the monkhood at 13, his brilliance immediately apparent — he quickly memorized all of the sutras and was given special responsibilities at the monastery.

But one summer, Chencho returned from school to find his parents anxious. Damchoy was being sent home.

Some gold and silver vessels had been stolen from the monastery — items Damchoy was supposed to be watching. “They were so expensive that he couldn’t imagine paying them back,” Chencho says. “I think that sort of just blew his mind.”

Chencho hardly recognized the person who walked through the door. His shy and sensitive brother had become manic and vainglorious, wearing a sword on his hip and acting like a little god. He raved — sometimes about killing people — and for nearly a week, Chencho and his exhausted relatives had to pin Damchoy down in his bed as he thrashed violently until dawn.

One day, Chencho was piggybacking his younger brother when Damchoy charged at them. He had a stone in one hand and a knife in the other.

For reasons Chencho will never know, his brother stopped himself at the last minute. Eventually, the family had Damchoy locked up.

Cast of characters

In the capital Thimphu, just past the main gates of Bhutan’s largest hospital, there is a two-storey building with a rotating cast of characters out front. Today: a monk in red robes, a young man gazing vacantly, a woman in track pants with a wreath of weeds on her head.

Like all Bhutanese buildings, this was designed in the traditional style, with trefoil-shaped windows, intricate cornices and auspicious Buddhist symbols painted on the wooden frames. It also has a crimson sign, announcing in yellow capital letters: PSYCHIATRIC WARD.

Chencho established the ward four years after being hired as Bhutan’s first psychiatrist in 1999. That year, he treated 151 patients. The following year, that number more than tripled. In 2012, 864 patients passed through his psychiatric department — and 76 people committed suicide in Bhutan, according to newspaper reports citing police statistics.

In a country of roughly 730,000, the 54-year-old has been tasked with delivering mental health care without a single psychologist, psychiatric social worker or mental health counsellor to support him. He does have one colleague — Dr. Damber Nirola, who became a psychiatrist in 2006 after Chencho coaxed him into it.

But on a recent summer day, Chencho is alone in the outpatient clinic.

As he arrives, dozens of anxious faces turn toward the bear-like man in the striped burgundy gho. Some smile to reveal red-stained teeth, a sign of the betel nut, which many Bhutanese chew as a mild stimulant. The crowd is a mix of young men in Snoop Dogg shirts and elderly farmers in ghos . At least one family has travelled for days to reach Bhutan’s only psychiatric department.

Chencho’s first patient is a tattooed drug addict whose friend recently died of an overdose. The World Health Organization defines mental disorders as including substance abuse, and addicts and alcoholics are among the most frequent visitors to Chencho’s psychiatric ward, where half of the 20 beds are reserved for them.

Alcohol has long played a part in Bhutanese culture and historical texts refer to its role in Buddhist rituals. Traditionally, it has been homebrewed but with rising disposable incomes — and growing production and imports — alcohol is now “perhaps the best-stocked and most ubiquitous commodity,” Chencho wrote in a 2005 paper. Liver disease caused by alcoholism has become Bhutan’s No. 1 killer.

Drugs are an emerging issue, too. The police registered their first drug case in 1981 — students studying abroad returned to Bhutan with drug habits, Chencho says. Many Bhutanese youth are now hooked on painkillers with street names like “N-10” and “SP,” mostly smuggled from India. As for marijuana, its skunky scent often invades one’s nostrils in Bhutan, where it grows wild, but smoking weed only gained popularity in recent decades. Before, it was just “pig food,” a trick for fattening livestock.

Chencho peers over his glasses at the skinny young addict. The Bhutanese are polite and diplomatic, but the psychiatrist has no qualms about being brusque.

“You want to be sober and get on with your life? Or do you want to die like your friend?” he asks. “It’s all in your hands.”

The drug addict insists he wants to get clean. But when Chencho presses him to stay in the ward for detoxification, he refuses.

The drug addict is followed by a man suffering from seizures, a woman with bipolar disorder, a teenager with schizophrenia, two alcoholics, four depressives and several patients Chencho calls “somatizers” — people with underlying mental issues that manifest as unexplained aches and pains.

One melancholy 16-year-old girl also shuffles into his office, staring at her pink plastic sandals. She has no idea what is wrong with her.

The mother says her daughter has been laughing and crying uncontrollably; she hasn’t been to class in four months. But both are frustratingly vague.

“Something’s going on there because she hasn’t been at school,” Chencho mutters. “(But) our families are not very good in the history telling. They always say what they think they should tell.”

Chencho admits her for observation. Later, he learns she has been picking fights at school, where she also broke four windows. She sometimes claims to be a famous figure in Buddhist mythology. In February, she fainted after a hysterical laughing fit.

Suspecting black magic, the family has been performing pujas , or Buddhist rituals, for four months. For this, they have spent 150,000 ngultrum (about $2,300), even travelling to a monastery in India.

Most Bhutanese practise Vajrayana Buddhism, or Tantric Buddhism, and evil spirits and deities are still widely blamed for illnesses and misfortune. According to a 2010 paper published in the Journal of Bhutan Studies , 83 per cent of 106 patients surveyed performed a religious ritual before coming to the hospital — of those, 41 per cent had already done more than five.

“They still think they have spirits getting into them, deities getting into them,” Chencho says.

But the psychiatrist understands. It was not so long ago that he believed the same thing.

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Locked up 10 years

After Damchoy went mad, his parents locked him in a storage room on the second floor of their home. His meals were slid through a hole in the door originally used by the family cat. An opening was cut into the floorboards so he could defecate into the pigsty below.

He stayed there for more than 10 years.

Occasionally, Damchoy jumped out the window and bolted for the woods, only to be brought back by fellow villagers. Twice, he snapped through metal handcuffs loaned by local police. After one breakout, Damchoy was found in a distant village, eating animal feed.

The family had only one explanation for why their quiet monk had become a raving madman.

“We really thought he was possessed by the deities,” Chencho says. “We thought that if we were able to appease the deity, then maybe the deity would leave him alone.”

The family performed several rituals. They gave away their antiques, fearing they were upsetting spirits in the home. They also consulted astrologers, or tsips , who told them a female deity had seduced Damchoy and taken over his body. Tsips are still frequently consulted in Bhutan — maybe for help on where to build a house or winning archery tournaments, the Bhutanese national sport.

Even in 1987, after Chencho became a doctor, he did not know how to help his brother. Psychiatry was not on his radar until two years into his medical career, when he met a psychiatrist from Bangalore.

Rangaswamy Srinivasa Murthy had been invited to Bhutan for four weeks as a consultant through the WHO. As soon as Chencho heard about Murthy, he borrowed an ambulance and picked up his brother and another psychotic woman he knew. They drove 90 minutes to see him.

Upon entering Murthy’s office, Damchoy dove under the desk, grasping at a phantom object.

“(Murthy) said, ‘Take him, take him. I’ve already diagnosed him,’” Chencho recalls, a smile tugging at his lips.

Murthy gave both Damchoy and the woman an antipsychotic drug. The woman fell asleep for days and woke up completely normal. “That was quite remarkable,” Murthy exclaims now. “That never happened in my life.”

The results were not as dramatic with Damchoy. But eventually, unbelievably, he began to improve.

“That,” Chencho says, “was the turning point.”

Supernatural explanations

Last year, 156 people were treated for depression at Chencho’s psychiatric department. But rarely do his patients say they are depressed — for one, there is no word in Dzongkha, Bhutan’s national language, for depression as a clinical condition.

Patients are more likely to complain of spirits or deities. But Chencho finds it pointless to argue about what he believes is actually making them sad. Instead, he tells them to keep their rituals — but how about also eating these pills?

Even with patients who don’t cling to supernatural explanations, Chencho struggles to convey that their problem is a mental one.

At Chencho’s psychiatric department, between the tattooed addict and the girl who laughs and cries, a 17-year-old boy is led into his office. For the second time in as many years, he and his father have travelled here from the far side of Bhutan.

“He can’t speak,” the father says.

The boy appears frozen. His mouth is fixed into a frantic, toothy grin, rendering him unable to talk or chew. His elbows stick out like angle brackets making a parenthetical statement of his torso.

Last July, the boy was diagnosed with catatonic schizophrenia. (This subtype of schizophrenia was eliminated as a diagnosis this year under the new Diagnostic and Statistical Manual of Mental Disorders .)

“In Bhutan, we still have a lot of catatonia,” Chencho says, explaining the condition is often characterized by stupor and rigidity. “We have a lot of this because they wait at home until they become completely frozen.”

But this boy was given medication the last time he came to the hospital — and he improved. He even went back to school. Why did he stop taking his pills?

“He got better,” the father says.

Chencho sighs.

“I think we told you that his disease is long-term,” he explains, gently but firmly. “If you give him medicine all the time he will be normal and he will go back to school.

“But he has to take medicine. Do you understand? Do you understand?”

The father does not seem to. He suggests that something is wrong with his son’s sinuses.

During Chencho’s ward rounds two days later, he sees the boy again. He is back on medication and his smile has faded, though he still has difficulty moving.

Ward rounds happen twice a week. They have the air of a courtroom — patients are brought in and seated before Chencho, who sits magisterially at the centre of a large table, flanked by nurses and staff members writing notes.

Today, there is also a drungtsho , or traditional doctor, attending Chencho’s ward rounds — a rare case of another healer accepting his standing offer to better understand psychiatry. Traditional medicine has been practised for centuries in Bhutan, shaped by Buddhist philosophy and herbal remedies, and drungtshos have their own hospital and Ministry of Health department.

The drungtsho, a young woman dressed in a green kira, listens attentively as Chencho explains his diagnosis of the catatonic boy. He asks someone to lift his arm over his head and let it go — the limb stays suspended before slowly descending, like a pebble dropping through hot wax. That’s “waxy flexibility,” Chencho explains, a common feature of catatonia. The drungtsho scribbles in her notebook.

After rounds, she describes her assessment of the catatonic boy. She suspects an imbalance in one of the three humours — perhaps a wind disorder since he cannot talk. She would recommend needle therapy in the throat and an herbal bath.

But the drungtsho is enthusiastic about what she has learned. If she encounters a catatonic patient and her treatments fail, she will refer the case to Chencho.