Samjhana* was an impressionable 12-year-old grade 7 student when she started becoming uncomfortable with her complexion.

I’m dark. I’m not pretty and no boy will ever fall in love with me.

Over time, this idea consumed her thoughts and took over her life. Once a cheerful and studious girl, she suddenly turned aloof, detaching herself  from her friends and losing interest in books. Slowly, she began to suffer from depression and eventually became suicidal. One day when she was alone at home she attempted to take her own life. She was saved, thanks to timely intervention by her family.

Samjhana’s story, while somewhat extreme, is representative of what many Nepali youngsters go through. They fall victim to emotional, psychological and mental health issues, but do not have the support systems they need to lift them out of their plight.

Lack of in-depth surveys and research means that concrete data is missing on the scale and nature of emotional, psychological and mental health issues faced by youngsters. But existing global statistics and expert opinions enable us to chart the gravity of the problems facing our youth and the failure of our current system.

Dr. Arun Raj Kunwar, child and adolescent psychiatrist at the Kanti Children’s Hospital believes that the global figure showing that 1 in every 5 children or young people suffer from some sort of emotional or psychological problem holds true for Nepal. A 2013 epidemiological study estimated that 37.5 percent of Nepal’s population suffers from mental disorders, while WHO’s global suicide survey a year earlier ranked Nepal seventh for suicides. These bleak numbers coincide with the multiple stressors that youngsters face.

Burden of grades, size 0, and more

“Yes the idea of beauty is inculcated in a child’s mind at young age,” Dr Kunwar explains. “But the media representations of beauty and the beauty product industry have such a widespread and powerful presence today that these are having grave repercussions in youngsters. Even before adolescence, children are already obsessed with how they look and whether they are beautiful enough. ”

Kunwar tells me about two  patients, girls aged 12 and 13, who watched a lot of Fashion TV and became so fixated on the idea of  achieving the “perfect” size zero body that they began to suffer from severe anorexia nervosa. He also tells me about Poonam, a grade 12 student, who was so intensely affected by the feeling that she was not beautiful that she took to self-harming behavior, a rare psychological condition of picking ones hair, since she was in class 6.

One’s body image is certainly a serious stressor among youngsters, but it is only one among multiple factors leading to emotional and psychological troubles.

Youngsters who appear at Kunwar’s psychiatry department identify a myriad of factors, many of which have been long accepted as causes of emotional distress in their age group– bullying and corporal punishment in schools, peer pressure, substance abuse, and issues in romantic relationships, conflicts with teachers and parents.

They also reveal the impact of more recent causes as well, such as the overuse of internet that increases the likelihood of emotional and mental health issues. A 2017 research conducted in 24 colleges in Kathmandu and Chitwan by the Institute of Medicine found that undergraduate students addicted to internet use were also showing symptoms of depression and insomnia.

But, there are more complex psychological factors, such as those emerging as a consequence of the Maoist conflict and subsequent political transformations in Nepal, which are quietly coming to the surface. Madhav Khatiwada, faculty member of psychology and counsellor at Kathmandu University, said that most recently an increasing number of students from the Madheshi community visit him for counselling with problems related to racial and ethnic prejudices directed at them from students of other communities.

No concrete numbers exist to reflect the scale of the impact of these individual factors. But as youngsters confront these multiple stressors, often several at a time, there is a general agreement among mental health workers that the biggest cause of emotional and mental health problems they face is the pressure to perform well academically – particularly in examinations.

“Parents and teachers have reduced the concept of education to good grades, which in turn is connected to good jobs. Education amounts to nothing more to them. The issues of emotional and psychological wellbeing are entirely ignored,” Dr Kunwar said.

This burden of good grades  has become enormous for young people across the globe, and the impact has been particularly severe close to home in India, where a young person aged 15-24 commits suicide every hour, according to a Lancet report. Dr. Kunwar has many examples of cases of suicide in Nepal that point to the seriousness of this problem. He talks about a a class 10 student due to appear for SEE. The student was put into tuition classes by his parents from 5 am to 8 pm. Unable to bear the intense pressure, he crumbled down with panic attacks, social phobia and depression.

In many cases, the consequence is far worse, as the data surrounding student suicides that follow the announcement of SLC (now SEE) results each year indicate. But of course, not all academic-related suicides (or teenage suicides for that matter) get reported. Nor do majority of the psychological problems get reported or end up in psychiatrist or counselling wards.

Illustration: Supriya Manandhar

Illustration: Supriya Manandhar

“Mostly, these factors affect youngsters slowly, creeping down to the core of their self-esteem and self-confidence, and slowly eroding them. Often their problems take time to take root and surface,” he said.

Avash, who attended a school considered to be one of the best in Nepal, is a potent example of the long-term consequence stressors during school years can cause. From a young age, no matter how hard he tried, the words on books or the mathematical formulas were something that he could not understand. So he frequently failed exams, and for this got severely bullied by peers and teachers for most of his stay at the fully-residential institution.

“I was 17 when I left school. But the bullying by both teachers and students continued to haunt me for many years,” Avash recalled. “I still struggle to come out of that bitter experience. Sometimes I feel that I would have been a much happier individual had I not been enrolled in school for this education.”

According to WHO, the roots of half of all mental illnesses start by the age of 14 while three-quarters by mid-20s. According to Dr. Kunwar, this number is where many of these youngsters come to fall later.

Lone battles

The slow and quiet manner in which emotional and psychological problems take root amongst youngsters is what makes the need of ensuring support when the issues are still in the beginning stages so vital. But help is not readily available.

In all those times she struggled with her body image, plunged into depression, became suicidal, Samjhana didn’t feel like there was anyone she could turn to for help.

“If only I had someone who I could share my problems when they had just come, most likely I could have stopped that thoughts on time and not suffered what I went through,” she said. After all, it was psychiatric help and counselling that had helped her in het recovery.

“If I could recover from reaching to such an extreme state of committing suicide, I only think that it would have been much easier to solve my problem when it was in the beginning stages, just about the time when the thought was affecting my daily life,” she shared.

The dilemma youngsters like Samjhana face is all too familiar for Dr. Kunwar, and he said it is only common in a country which gives little attention to mental health issues, and grapples with a shortage of resources.

Only 0.22 psychiatrists and 0.06 psychologists are available per 100,000 people, and budget allocation is a nominal 1 percent of the total health budget making up a meager 0.04 of total budget.

Yet, the bigger problem lies elsewhere. In many interactions with parents, teachers, even policymakers and youths in his capacity as a psychiatrist, Dr Kunwar often has a hard time convincing people that children can feel stress and emotional problems too.

“This’s the crux of the problem. That even children can feel stress and develop emotional issues is something that doesn’t make up even a flicker of thought for parents and teachers,” Kunwar said.

Lack of awareness is not the only issue at hand. Khatiwada, a man who survived a lone battle with depression as a college student, who was once a school teacher, and is currently a trained psychologist who teaches as well as provides counselling to students at the Kathmandu University, can offer perspectives on this problem from a unique vantage point.

“This adamant manner in which schools and parents are only concerned about creating ‘toppers’ and don’t even think about students’ emotional issues, let alone have guidelines and policies to address these, it can’t be simply an attitude to do with a lack of awareness,” he said. “It’s denial too.”

This denial, he said, does not exists in isolation, but is linked to deep-seated stigma surrounding mental health issues. Although no data exists for Nepal, the WHO data for the European Union showing that nine out of every 10 mental health patients reported facing discrimination points to  the pervasive nature of stigma surrounding mental illnesses.

“In its core, lack of acceptance is what leads people to suffer from emotional and mental health problems,” Khatiwada said. “Stigma is so strongly rooted that anyone with the slightest of emotional issues are prone to becoming isolated.”

It was stigma which led Khatiwada to hide his depression. And it’s stigma that pulls back youngsters like Samjhana from opening up about their mental distresses.

Now, with his experiences, and training as psychologist, Khatiwada can tell with certainty that breaking stigma is where the answer lies in addressing the myriad mental health and emotional issues that youngsters face.

“We should strongly sensitize youngsters on emotional and mental health issues, so there’s no longer stigma attached to it and they can openly share about the emotional issues they face due to multitude of stress factors,” he said. “Stressors are only increasing and youngsters feel more pressure than ever today, so if we don’t act now, the mental health state of youngsters will only get worse.”

And the moment might be just right to take concrete steps to help youngsters with emotional, psychological and mental health issues. One indication is that the number of patients seeking help in the psychiatric departments in hospitals in Kathmandu and other urban areas are increasing. At the Department of Psychiatric at the Kanti Hospital, number of patients has surged from 660 in the first year to 3300 last year since its establishment two and a half years ago.

Illustration: Supriya Manandhar

Illustration: Supriya Manandhar

“It’s a sign that a section of parents and teachers are becoming aware about mental health issues in youngsters,” Dr Kunwar said. “This is obviously helping break the stigma.”

Most youngsters who reach psychiatric wards already have serious problems, which means that they suffered through prolonged periods of distress which likely affected their performance, opportunities and relationships before they sought help. Mental health workers like Kunwar and Khatiwada stress on the need to take a proactive role in identifying factors leading to emotional and psychological issues in youngsters. The creation of an environment where problems can be shared will allow for issues to be dealt with in their initial stages before they get worse. Kunwar and Khatiwada stress the importance of creating an environment where youngsters feel free to share emotional issues with peers or teachers or parents as soon as problems emerge.

“For long in Nepal, families and schools have knowingly or unknowingly contributed to erode emotional wellbeing of youngsters. It’s high time they became a part of the solution now, and not of problem,” Dr. Kunwar said.

Khatiwada has a practical suggestion how schools could start this.

“Every day every school starts with a morning assembly where teachers lecture on discipline and good grades and “deviations” from school rules. If they talk about the emotional problems and stresses youngsters could face and encourage them that they can readily share those with teachers or peers or parents, if they do this every single day, won’t this sensitize them to open up more about problems they face?”

* Names have been changed to protect privacy.

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