By Shiva Raj Mishra & Vishnu Khanal, Perth
6 January 2016
Nepal has one of the lowest number of psychiatrists per 100,000 population. According to a World Health Organisation report titled Assessment Instrument for Mental Health System, only 32 psychiatrists, six psychologists and 16 other medical doctors (not specialised in psychiatry) serve Nepal’s mental health sector. And there are no social workers or occupational therapists working in the area.
“The majority of psychiatrists and mental health professionals are concentrated in urban health centres which means rural areas are deprived of even the most basic psychiatric services”, despairs Jagannath Lamichhane, the coordinator of the Movement for Global Mental Health. If mental health was already a bad story in Nepal, the April 2015 earthquake made it even worse. The mega disaster killed nearly nine thousand people, injured over 18,000 and displaced nearly a million victims. Needless to say, this escalated the mental health burden among survivors.
“The repetitive loss and stress due to conflict and disasters are a public health concern that urgently needs to be addressed”, Mr Lamichhane urges. Even before the earthquakes, Nepal had a 14% prevalence of post-traumatic stress disorder (PTSD) and a higher rate of depression and generalised anxiety – mainly due to the armed conflict between government forces and Maoist guerillas (1996 and 2006).
However, there have been increased reports of anxiety and PTSD since the April and May 2015 earthquakes. According to Prof Saroj Prasad Ojha of Tribhuvan University Teaching Hospital, in some districts almost 25-30% of the affected population display signs of mental illness. This clearly shows the implications of the latest earthquakes, he opines. Majority of his patients have conditions related to anxiety and depression, he adds. This is in line with an earlier study by Murthy & Lakshminarayana (2006), the World Health Organization. The study reported that crisis situations can increase the risk of mental disorders, with women being more affected than men. Children, elderly and the differently abled are also severely affected.
“During the relief and response operations in the immediate aftermath of the April earthquake, the problems of psychological distress never attracted attention of the government, the civil society and foreign medical teams”, Mr Lamichhane says, “Patients were treated in temporary medical camps with virtually no space for mental health counselling”.
In the opinion of Saki Thapa, the Mental Health Coordinator at Britain Nepal Medical Trust (BNMT), while the immediate national and international response was encouraging, it lacked long-term vision as services provided were piecemeal and fragmented and even that was discontinued few months after the quake.
When it comes to addressing the psychological needs of earthquake survivors, one must not neglect sustained livelihood as an important first step to recovery, Mr Lamichhane reminds, “Inability to link mental health programmes with livelihood will jeopardises its impact”. Fragmented programmes yield less impact when not backed by sensible interventions to support income generation. After the earthquakes, nearly a million people were displaced from their homes after they lost their harvest and livestock. However, so far they have received minimal support. “Whatever support has been provided, it has come in a piecemeal approach”, he points out.
Nothing is more concerning to Ms Thapa than the duplication of work. She estimates nearly two dozen NGOs provide the same services in her district. Also, the ones who actually benefit from these sporadic support programmes are those living close to cities or those who have access to motorable roads. “But the poor, illiterate and geographically disadvantaged are not getting what they need for living”, she adds.
“Those who have witnessed the death of their family members and relatives often suffer from conditions such as PTSD and depression that in turn affect one’s self esteem and morale”, Prof Ojha warns. “Anxiety and depression can hamper a person’s daily functioning, which can improve with psychosocial support, and medications in severe cases,” he states. Some are resorting to alcohol as a means of coping with the stress. This can further increase dependence and deteriorate mental health, he warned.
Medical Officer Rajan Ghimire from Dolaka district shares his experience of working with displaced communities. According to a Post Disaster Needs Assessment (PDNA) report, 51 out of 53 health facilities in his district were completely or partially damaged by the earthquakes. Mr Ghimire who counselled hundreds of families after the devastating April earthquake, describes working with displaced communities as the most challenging task he ever undertook during his career. “We don’t have any psychiatrist”, he highlights the need of psychiatrists at his hospital. He says many children had PTSD developing into insomnia, vague abdominal complaints and fear, “These children need follow-up and continuous psychological support!”
Another medical officer who works at a hospital in Kavre district says most of the patients he encountered had physical symptoms: palpitation, heavy breathing, lack of concentration, and lack of sound sleep. Dr Sugam Gauli is the one of few doctors working at an upgraded primary health care centre with a capacity of 15 beds. Here, he provides counselling about relaxation techniques (breathing and counting techniques) to the cases of mental disorders.
Mr Lamichhane, on the other hand, claims that the earthquake has also created some opportunities to tap. For instance, people are now more open to discuss their emotional issues and sense of distress. Amid continuing aftershocks, people have started to visit hospitals for psychiatric services. Nepalis today are readier than ever to lay bare their psychological issues. He explains that the earthquake has given people with mental disorders a crucial window of opportunity to come out and seek health services. “The society now has started to recognize distress as a normal part of life, which has increased service seeking behaviour”. Mr Lamichhane is nevertheless worried that “earthquake fever” will fade away, and the stigma associated with mental illness will quickly take over people’s candour in discussing their mental illness.
To stop this from happening, he argues, mental health literacy among the various sections of the society is vital.
Despite this recognition of a greater burden of mental illness, it remains under-prioritized and under-funded. Lack of institutional and financial capacity, insurance system and qualified human resources continue to weaken Nepal’s mental health response – even after the lessons learnt following the 2015 earthquake. What is needed is drawing more attention, with increased efforts on awareness programs via public health measures to increase demand for service seeking.
In the opinion of Anil Shrestha, a member of Nepal Australia Mental Health Network, the key priorities for the Nepali government should be on strengthening mental health services at peripheral level, strengthening referral networks, and continuing psychosocial counselling. As mental health problems are part of daily lives, the response, which so far is entirely clinical, would not add much value if their family and community are not engaged. His network has trained psychosocial counsellors and is expanding in closer collaboration with NGOs and the Nepali government to initiate programs at community level.
Shiva Raj Mishra, a columnist with southasia.com.au, writes on public health. He can be reached at firstname.lastname@example.org and @SRajTweets.
Vishnu Khanal, PhD, Curtin University is focused on maternal and child health, and mental health. He can be reached at email@example.com