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.
Mental health issues should be thought of as a disability
The WHO says that by 2030, disability due to mental health illness will become leading cause of disability, and have tremendous economic impacts. Could you explain this concept of disability caused by mental health issues?
I would rather like to call it psychosocial disability, rather than mental health disability. The term psychosocial disability has wider connotations, including the debilitating impact that social attitudes towards psychological problems can have on the exclusion, deprivation, biases, and discrimination experienced by those who have mental health issues. Being labeled, excluded, and discriminated in this way adds to the invisible disability created by cognitive impairment, behavioral limitations, and emotional vulnerability.
Psychological and mental health problems are highly debilitating illnesses. Depending upon the disorder and its intensity, patients can have, to varying degrees, mood swings, lethargy, fatigue, restlessness, and many other distressing experiences. Patients might be forced to remain entirely out of the workforce for a given period of time when they are seeking treatment. And even after they become economically active, there are times when they cannot focus on work, but instead need to rest a lot, and seek medical attention or therapies. And for illnesses such as schizophrenia, patients might need sustained treatment and care for the rest of their lives. All this comes into play when we think about disability due to mental health issues.
So it has big economic implications?
Of course. When individuals are out of work due to their mental health issues, their economic productivity is reduced. An article in The Lancet, the preeminent peer-reviewed medical journal, shows that mental health issues are amongst the most disabling diseases, accounting for the largest socio-economic burden – 32.4 percent – in terms of productive years lost due to disability caused by disease. The cost of disability induced by mental health problems is huge in terms of lost productivity, work satisfaction and overall happiness. For instance, the WHO says that depression and anxiety cost the world $1 trillion annually in lost productivity.
Are health professionals and policymakers in Nepal thinking about this issue?
Sadly, the concept of psychosocial disability is hardly known in Nepal. Even the state has not internalized the toll of mental health and psychological problems on economic growth and development.
An individual might be inefficient or unproductive in their studies, work, or anything else they are doing, due to mental health issues. But whether at home, the workplace, or school, Nepali society is more likely to attribute this to laziness or insincerity towards work.
Speaking from my own experience, I was very fortunate that the principal of the school where I taught was very understanding of my condition and allowed me days off, so I could get sufficient rest when I was not having the best of days. But most people in Nepal who work and suffer from mental health or psychological problems have to face very bad conditions. I’ve known friends, colleagues and other people who lost their jobs because of their condition.
A good policy should make room for medicines, therapies – and systemic socio-economic change
Nepal first introduced a Mental Health Policy in 1997. Twenty years later, in 2017, the Ministry of Health drafted a new Mental Health Policy. It sounds like there are still some policy gaps.
The 1997 Mental Health Policy only emphasized a medical approach to understanding and treating mental health problems. But studies have shown that mental health is a multi-sectoral and holistic issue: physiological and psychological, as much as it is social, cultural, and economic. By focusing on a purely medical approach, the old policy ignores the roles of psychologists, counsellors, social workers, and others in tackling mental health challenges.
Mental health is a public health issue as well, determined by economic, social, environmental, and cultural conditions. A comprehensive policy would need to address these determinants. For instance, since poverty is a major cause of mental health problems, only prescribing medicines and delivering therapies is not be enough ensure mental health. Solutions should be sought in the broader socio-economic system itself.
So, is the new policy an improvement?
So much has happened in the two decades since the first policy, in terms of advocacy, awareness, education, and exposure to international norms and policies with regard to mental health issues. Perhaps as a result of this, the new policy identifies all the crucial problems and gaps in relation to Nepal’s mental health space, and addresses many gaps in the first policy.
I feel the most significant leap is that this new policy recognizes the psychosocial disability model to mental health problems. In doing so, it recognizes that mental health problems could bring difficulties in all aspects of an individual’s life and endeavors – social, cultural, economic, and others – and devise appropriate programs in line with the Convention on the Rights of Persons with Disabilities (CRPD).
There are some important ways in which the policy is forward-looking:
- It identifies the disease burden occupied by mental health issues and the need to allocate federal and provincial budgets according to this.
- It understood the need for a national-level survey on mental health – the survey is already underway – in order to use data to devise and implement informed programs. It also notes the need to promote mental health research.
- It highlights the importance of integrating mental health issues in the information system of public health issues under government priority. This list includes maternal health, vaccinations, family planning, nutrition, child health, school health, and HIV, among others.
- It also recommends increasing referrals to those with mental health problems.
- It highlights creating standard curriculum to train local level health personnel, and providing psychosocial support at all levels of health facilities.
- It envisions the creation of a separate government body or division focusing on mental health.
- It sets down the need to include mental health as a component of the fundamental right of basic health of all citizens.
- It states the need to treat, protect, and rehabilitate those with mental health issues on the streets and in prisons.
- It envisions programs based on social justice to make mental health accessible to disadvantaged and marginalized communities, children, women, those with disabilities, the elderly, and sexual minorities.
That sounds like a major improvement. Are there any other specific points or issues you feel the policy should include?
Policies related to the treatment and rehabilitation of patients should address the interrelated psychological, social, economic, environmental, and cultural factors that affect them.
Once the national mental health survey is successfully completed, it should provide crucial information on which to base concrete initiatives and policies.
I think that it is important for policies to specifically consider the following:
The first is to do with educational institutions, which largely shape children’s ideas and world views. The policy must formulate implementable strategies for creating systems and the infrastructure in schools and education institutions to address students’ psychological and mental health issues. Mental health should also be made a core component of the curriculum, to help tackle the stigma attached to mental health problems.
The other important area that needs policies to govern mental health and psychological issues, is workplaces. The rights of employees with mental health problems must be safeguarded. this should include clear rules to ensure employees seeking treatment continue to receive their salaries for a certain period of time.
Psychosocial disability should be acknowledged, and the rights of people with psychosocial disability should be ensured. For instance, there should be guidelines to provide specific social security allowances to people with psychosocial disabilities.
Equally, it is vital to have policies that address malpractices that have emerged due to the lack of oversight and policies. Even in Kathmandu we find so-called treatment centers for mental health and psychological problems that claim to offer alternative treatments. I myself became a victim of such an institution. There are also people claiming to work as psychologists and counsellors who use questionable methods and are not open about their qualifications and training.
Mainly in villages, where visiting shamans is a common practice, policies should aim at training and teaching shamans and other traditional healers to also refer people to medical practitioners like psychiatrists, counsellors, or psychotherapists.
To help people in our context, western models of intervention are not enough. There needs to be policy support for studies and research to find out what indigenous and cultural therapeutic components offer, so they can be used alongside so-called evidenced-based western models.
The many ways we can all understand mental health better
The changes on the policy level are positive. On a human level, what should we all be aware of? And what do we misunderstand about mental health?
In our society, if you have a family member who is facing mental health issues, that person is seen as tarnishing one’s status and prestige.
Perhaps many other misconceptions surrounding mental health stem from this belief system. Even today, it is common to attribute mental health or psychological problems to planetary misalignments or a play of spirits.
A second misconception is that seeking mental and psychological help is a sign of weakness, which in turn comes from the belief that people become mentally ill because they are emotionally weak. This makes parents, guardians, and teachers to try to ‘cure’ such illness by advising those suffering that “man darho parnuparcha” (“you should be emotionally strong”). This could have an actively detrimental effect on patients, who often already have low self-esteem.
The third misunderstanding is that mental or psychological problems cannot be cured or that once a person becomes mentally unwell, they have lost their sanity. Yet, barring extremely serious mental health problems, most mental health issues are curable. Even people with illnesses such as schizophrenia can lead normal lives, managing their symptoms.
Finally, there is an attitude that medication is highly habit forming and cannot be given up. While it is true that patients might have to take medication for a sustained period for certain illnesses, those suffering from depression or anxiety disorders have to do so only for a certain period of time.
Read Part 1 of this interview to know more about the state of mental health in Nepal, what factors affect it, why suicide rates are so distressingly high, and treatment prospects.
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