Mental health issues have had more visibility in Nepali media this year for reasons distressing and positive. In August, a government official died by suicide in Singha Durbar, and indeed, suicide rates are rising across the country. At the same time, there is a nationwide government-led survey of mental health underway.
Nepal lacks comprehensive national-level data about our mental health status. But estimates paint a grim picture. The World Health Organization (WHO) says that more than 300 million people globally suffer from depression, a figure that increased by more than 18 percent between 2005 and 2015. Millions of others suffer from a myriad of mental health issues. In 2012, the global health body found that close to 800,000 people take their own lives every year.
Small studies and Nepal’s medical practitioners say that mental health trends in Nepal roughly track global data. Yet, as anyone who deals with mental health issues, whether directly or while taking care of friends and family knows, we have too few trained personnel and not enough infrastructure to meet the needs of those affected. Our policies, too, are in a formative stage. All this is worsened by a lack of awareness and the stigma that surrounds mental health issues.
Madhav Khatiwada, 48, was 24 when he had his first panic attack. What followed was a 15 year-long struggle with anxiety disorder and depression. He thus experienced firsthand the consequences of a society having inadequately trained personnel and poor infrastructure to deal with mental health issues, including malpractice and opportunistic endeavors.
Upon recovery, Khatiwada, then a school teacher, pursued a master’s degree in psychology and trained as a psychological counsellor. He has since worked with various organizations on mental health at the grassroots level, closely observing the state of mental health in Nepal’s villages. He is currently a lecturer of Psychology, and English Language and Communication at Kathmandu University. He is also a counsellor for the students, and so sees daily the emotional and psychological issues facing young people.
Ahead of the WHO-designated World Mental Health Day on October 10 to raise awareness about suicide and its prevention, Prawash Gautam spoke at length with Khatiwada about mental health in Nepal.
In Part 1 of this conversation, Khatiwada discusses the state of mental health in Nepal, treatment options, and the distressing increase in suicide rates. Part 2 looks at the projections for mental health in Nepal, and explores what we can do – on a policy level and as individuals.
The many transformations in Nepali society can have mental health implications
Nepal Health Research Council (NHRC) is conducting a national mental health survey. Is this an indication that Nepal is facing more mental health issues than previously?
This initiative indicates that mental health and psychological problems affect a large Nepali population and acknowledges the need or national level data to address the needs of those who need help and also design appropriate policies.
The report is expected in 2021, so we won’t have a clear picture until then. But how have the figures looked in recent years? We keep hearing that mental health problems are rising in Nepal, but does the data back that up?
Various smaller studies focusing on specific populations give a good indication of Nepal’s current mental health scenario. The WHO says that one in every four individuals has a mental disorder at any time, and mental health professionals in Nepal believe is true for Nepal’s population as well. Even the NHRC’s pilot survey conducted in 2018 on around 1,700 people showed that 11.2 percent of adolescents and 13.2 percent of adults were suffering with mental health issues. A leading cause of suicide is also mental health disorders, and Nepal has been seeing increasing suicide rates.
The 2017 National Mental Health Policy, which compiles estimated data from various sources, says that between 27.5 and 33.4 percent of the population is dealing with depression, and that anxiety is a challenge for between 22.9 and 27.7 percent of Nepalis. It also estimates that 20 percent of children and adolescents suffer from mental health or psychological issues.
According to the WHO, low-income countries are more vulnerable to mental health issues due to economic hardship, conflict, and disaster. All these conditions apply to Nepal.
In other words, emerging socio-economic factors can also be stressors that lead to mental health issues.
Broadly speaking, the major stressors that exacerbate emotional and psychological problems in our society are poverty, unemployment, lack of awareness, superstitious beliefs, authoritarian parenting, man-made and natural calamities and violence, chronic physical illness, gender and sexual violence, family dispute, and bullying, among others.
I see six major emerging stressors in Nepal.
The exodus of Nepali youth to foreign countries for employment is having a big impact on family values in Nepal. There are more family feuds and families separating due to extramarital affairs, which in turn lead to mental health disorders or psychological problems.
The feminist and LGBTIQ movements in Nepal are helping women and LGBTIQ individuals to be more empowered, which patriarchal families and societies do not readily accept. This tension is another emerging stressor.
Globalization and materialistic values are emphasizing the need to achieve and win. The stress and confusion this causes affects the mental health of young people, in particular.
In urban areas, changing family structures and values are impacting children’s mental health. For example, in nuclear families where both parents work, children can essentially grow up without their fathers or mothers.
With so many Nepalis permanently settling abroad, their elderly parents still here are increasingly suffering from loneliness and psychological problems.
Overuse of the internet is also causing stress and mental health issues among youngsters. There was even a study in 2017 among undergraduate students in Nepal which linked internet addiction to depression and anxiety.
Nepal has a high suicide rate, particularly for women and in Ilam. We don’t know why
Suicide is on the rise in Nepal. What is causing this?
The WHO has identified suicide as a major mental health issue, and has found that it is the second leading cause of death amongst youngsters globally, and overall, one individual dies by suicide every 40 seconds.
Though Nepal lacks national-level data on suicide, a global suicide survey by WHO based on age-standardized model ranked Nepal seventh for suicides at 24.9 per 100,000, and depression as the major suicide trigger. Nepali women have the third highest rates of suicide globally, in South Asia second only after Sri Lanka. A 2008/09 survey found suicide to be the leading cause of death among girls and women of reproductive age (15-49 years) in eight districts and across ethnicities.
Although WHO’s 2016 estimates showed that suicide had halved, from 15.4 per 100,000 in 2005 to 8.8 per 100,000 population in 2016, in Nepal, media reports and police data suggest escalating suicide rates in various districts across the country. Clearly, we need national data on suicide in order to devise appropriate preventive actions.
We lack concrete action plans. One of the biggest drawback is there exists no reliable data and analysis on suicide [other than the few studies cited above], and most data is based on police reports. Suicide can have multiple and discrete causes related to psychosocial, genetic, and biological issues.
Let me give the example of my home district, Ilam. Ilam has long been infamous as the district with Nepal’s highest suicide rate. To make matters worse, suicide cases in Ilam are underreported. Even police are unable to provide accurate statistics. Though we can know the causes of suicide in general, based on mental health and psychological literature, we have no cues as to why Ilam has higher number than the national average. There has been no research exploring what makes the Ilam context special.
There is also a lack of awareness, and no extended awareness campaigns. Health personnel also do not have access to trainings or helplines that could assist them in providing support.
What can communities and the state do, to address these grim suicide statistics?
I feel that the first thing the government has to do is to raise awareness on issues related to suicide, to help break down the stigma attached to mental health and suicide. It means that people at least talk about their suicidal thinking and intentions, as they talk about other issues of life. But perhaps even before this, I feel that one immediate measure that the government has to take is to set up helplines in Ilam and other districts where suicide rate is high, and gradually make this facility available round the clock in health facilities across the country. Currently, only four helplines exists, of which two are run by Tribhuvan University Teaching Hospital and Patan Hospital and two others by organizations. In this age of internet and instant communication, everyone has a mobile phone. The state has to tap into this and create hotlines where anyone with suicide ideation can contact and receive instant counseling support.
There are health posts at the local level and almost every village has an aama samuha (mothers’ group). School teachers, students, community leaders, traditional healers are other important groups of people who can be trained and mobilized to spread awareness about not only suicide but mental health issues in general. Mother’s groups in particular have successfully solved problems and created awareness in local communities.
Once immediate measures are in place, the government should carry out surveys and research to identify the factors leading to suicide, and launch awareness campaigns, and develop and implement suicide preventive strategies based on the findings.
Medication must be prescribed carefully, and supplemented with some form of therapy
You paint a bleak picture. You have seen the issue from many angles: as a patient, a student, and now as a psychology lecturer, counsellor, and mental health activist. How would you describe the state of human resources and infrastructure available to treat mental health in Nepal?
A 2007 report by the WHO, Mental Health System in Nepal, showed that we have 0.22 psychiatrists and 0.06 psychologists per 100,000 people. One percent of the national health budget goes towards mental health – that is just 0.04 percent of the total budget.
There certainly are more psychiatrists, psychiatrist nurses, clinical psychologists, psychologists, and psychosocial counsellors than at the time of the WHO report. The National Mental Health Policy-2017 counts around 150 psychiatrists, 28 clinical psychologists, 70 psychiatrist nurses, 150 psychologists, and 700 trained counsellors. Yet, these figures remain good indicators of the dismal state of Nepal’s mental health infrastructure.
Government hospitals with mental health department do not have sufficient beds, while private hospitals and clinics are too costly for poor patients. Counsellors and psychotherapists are also disproportionately concentrated in private hospitals and personal practice centers. Moreover, mental health hospitals and health personnel are concentrated in urban areas, especially Kathmandu.
The lack of adequate mental health infrastructures and personnel is also impacting future mental health personnel. Students in training do not get sufficient exposure to clinical settings during their training, which then directly impacts their practice.
It appears that mental health interventions in Nepal depend primarily upon psychiatric consultations that end in prescription of medication. Is this sufficient?
Yes, this is the first line intervention for mental health and psychological problems in Nepal. From my own experiences, I can say that almost always, psychiatrists ask for symptoms and a few other questions, and then prescribe medication. They do not at all consider the root causes or stressors that led to the mental health problems in the first place.
Medications have side effects, but doctors don’t often counsel patients and their families about even the simplest and most common ones. For instance, some psychiatric drugs make patients very dizzy, sleepy, and lethargic. When the families do not know this, they might be led to think that the patient is becoming lazy instead of taking steps to get well soon. Such situations can cause misunderstandings.
Not informing patients about side effects could lead to negative or unfavorable behavior by the patients which could further worsen their condition. I myself faced very strong side effects but the doctors never gave my any suggestions about how I could lessen or cope with them. During my fieldwork in Dhading district, I found that a young college student who had been taking psychiatric medicine was suffering from severe side effects. The local shaman attributed these symptoms to an unappeased spirit as a result of the wrong therapeutic intervention, so the boy gave up taking his medicine. After some months, his condition worsened to the point that he was on the street and could not manage anything.
So what would a holistic treatment process consist of?
Mental health and psychological problems are mostly a result of several psychological, social, environmental, physical, and bio-physiological situations, and individuals’ response to them. The response may take the form of distressing emotions, maladaptive behavior or physical or physiological symptoms.
Medicine obviously helps, but mostly to mitigate physical and physiological problems rather than going to the roots of stressors. There is ample research showing that the combination of medicine and psychotherapy not only speeds up the recovery process but also decreases the chances of the patients relapsing, since any underlying psychological and emotional issues that led the illness in the first place are also resolved. So psychiatrists must make it a point to ensure that every patient sees a psychologist or counsellor. There are more psychologists and trained counsellors in Nepal now, what with TU and other institutions offering training and degrees in psychology, as well as some Nepalis training abroad.
In counseling and psychotherapy, we can incorporate numerous relaxation techniques that have been developed in our own culture, such as yoga and meditation. There has been much research demonstrating the positive impact of these techniques on mental and psychological problems.
For many mental health and psychological issues, group therapy or peer support are highly effective. Those suffering from mental health issues have symptoms of low self-esteem, hopelessness, loneliness, worthlessness, fear, and apprehension. And the fact that they are suffering from mental health issues only worsens these symptoms, since mental health problem is so highly stigmatized. So meeting others who have similar health issues and experiences can have great therapeutic value. Some social organizations working on mental and psychological health have been running such therapies.
Part 2 of this conversation between Prawash Gautam and mental health advocate Madhav Khatiwada looks at the projections for mental health in Nepal, and explores what we can do – on a policy level and as individuals
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