COUNTRY Insight and challenges: mental health PROFILE services in Yugesh Rai,1 Deoman Gurung2 and Kamal Gautam3

1MD, Psychiatry Trainee, Essex Kanti Children’s Hospital is the only full-time out- Partnership University NHS This paper describes the current state of clinic for children in Nepal. There is no Foundation Trust, UK. Email: mental health services in Nepal and reflects [email protected] dedicated in-patient unit for children. on the significant changes over the past 2MRCPsych, ST4 (General Adult/ Non-governmental organisations (NGOs) have Old Age Psychiatry), Lancashire decade. The main challenges to overcome are Care NHS Foundation Trust, UK played a vital role in the delivery of mental health proper implementation of community-based 2 3 services. Community mental health services were MD, Executive Manager and services, the high suicide rate, stigma of Consultant Psychiatrist, initiated in the 1980s by the United Mission to mental illness, financial constraints, lack of Transcultural Psychosocial Nepal (UMN).3 In the 1990s and early 2000s, Organization Nepal (TPO Nepal), mental health legislation and proper , Nepal NGOs such as the Centre for Victims of utilisation of human resources. Torture, Nepal (CVICT), the Centre for Mental Keywords. Nepal; mental health – services; low- and middle-income Health and Counselling Nepal (CMC-Nepal) countries; psychiatry; mental and the Transcultural Psychosocial Organization health. Nepal is a landlocked country situated in South Nepal (TPO Nepal) provided mental health and Asia between India and China. It became a repub- fl First received 3 Aug 2020 psychosocial care to the victims of civil con ict Final revision 6 Oct 2020 lic, federal state with the promulgation of the con- and the Bhutanese refugee crisis. NGOs have Accepted 15 Oct 2020 stitution in 2015. It is ethnically diverse, with 125 also contributed to the scaling up of community ethnic groups and approximately 123 languages doi:10.1192/bji.2020.58 mental health programmes, in collaboration with spoken as tongues. The country has the MoHP. Copyright © The Authors 2020. recently emerged from political transition and a One of the hindrances to the development and Published by Cambridge massive earthquake. The current healthcare deliv- University Press on behalf of the delivery of mental healthcare is the lack of a social Royal College of Psychiatrists. ery system is organised as a tiered referral system. welfare net. Most mental healthcare is paid for This is an Open Access article, At the basic level are community health units, distributed under the terms of out of pocket in Nepal. However, depression, the Creative Commons health posts, urban health clinics and primary hos- psychosis, alcohol use disorder and epilepsy were Attribution licence (http://creati- pitals (including primary health centres). More recently included in the DoHS’s Basic Health vecommons.org/licenses/by/4.0/), complex and serious cases are referred to second- which permits unrestricted re-use, Service Package 2075 (2018). Thus, the care and distribution, and reproduction in ary-level hospitals, tertiary-level hospitals (provin- treatment of these disorders will be free of cost. any medium, provided the ori- cial and above) and eight specialised hospitals. ginal work is properly cited. included are diazepam, amitriptyline, The Ministry of Health and Population (MoHP) chlorpromazine, trihexyphenidyl, phenobarbitone, There is a podcast available for formulates overall health policies/plans and regu- carbamazepine, sodium valproate, risperidone and this article at: https://soundcloud. lates, monitors and evaluates health activities and com/bjpsych/bji-2020-58 thiamine. outcomes. In 2018, the and Control Division (EDCD) of the Department of Epidemiology of mental disorders Health Services (DoHS) was designated as the The first epidemiological field survey conducted focal unit to oversee mental health in Nepal. in the Kathmandu Valley in 1984 estimated the The mental health programmes in the country prevalence of mental illness to be around 14%. are operationalised by the Non-Communicable A recent pilot study of the National Mental Disease and Mental Health Section. Health Survey reported the prevalence of mental disorders to be 12.9%.3 Suicide (16%) was the Mental healthcare system leading cause of among women of repro- Mental health services in Nepal started out in ductive age, with 21% of suicide occurring below 4 general hospital settings. The first psychiatric out- the age of 18 years. In comparison with other patient service started in 1962 and in-patient countries, suicide among women (20 per treatment in 1964.1 A mental hospital was estab- 100 000) is higher than among men in Nepal lished in 1984 and it moved to its current location (3rd highest cause of death among women 5 in Lagankhel, Lalitpur, in 1985. It is the only versus 17th highest among men). The National mental hospital in Nepal and has a capacity of Mental Health Survey is being conducted by the 50 beds. Nepal never had a mental asylum. National Health Research Council in collabor- Mental health services are provided by the ation with the MoHP and World Health psychiatry units of medical colleges, provincial Organization (WHO) and is expected to be com- government hospitals and a few private hospitals. pleted by January 2021. The total number of in-patient psychiatric facil- ities is 25 and the number of beds is 500. Clinics Stigma and cultural perception of mental have been initiated in different subspecialties, illness such as child, memory, and addiction. The mind and the body are considered distinct The Child and Adolescent Psychiatry Unit at entities in Nepalese culture, thus mental illness

BJPSYCH INTERNATIONAL VOLUME 18 NUMBER 2 MAY 2021 e5, 1 Downloaded from https://www.cambridge.org/core. 02 Oct 2021 at 00:03:09, subject to the Cambridge Core terms of use. Table 1 Mental health services and resources in Nepal

2020 200810 Health budget as a proportion of national budget 6.15% 6.5% Mental health budget as a proportion of the total health budget 0.2% 0.8% Number of registered doctors in Nepal 26 346 6719 Number of psychiatrists 200 39 Number of in-patient psychiatric facilities 25 – Number of psychiatric beds 500 385 Child psychiatrists 30 Old age psychiatrists 00 Clinical psychologists 30 (MPhil) >9 200 (MA) Psychiatric nurses 50 48 Psychosocial counsellors (trained using the 780 h curriculum of NGOs) 700 – Community-based psychosocial workers (trained in basic emotional support) >300 –

NGO, non-governmental organisation; –, not reported.

is viewed as being separate from physical illness.6 The number of psychiatrists has grown from 40 Mental illness is perceived as a ‘spiritual dysfunc- in 2008 to 200 at present. Similarly, there has tion’ or ‘weak mind’ and attributed to spirit pos- also been growth in the numbers of clinical psy- session, black magic, divine wrath and misdeeds chologists and other mental health professionals. committed in previous lives (karmako phal). Details of the mental health workforce are pre- There is a strong belief in traditional healing sented in Table 1. and the first point of contact for most people is the traditional, religious or faith healers (e.g. dha- Mental health policy and legislation mis, jhankris, baidangis and bijuwas). A comprehensive National Mental Health Policy Several emotional and somatic idioms of dis- was first formulated in 1996 and incorporated in tress have been identified specific to the the Ninth Five Year National Plan by the Nepalese cultural context.7 Emotional idioms Government of Nepal.9 However, the implemen- are expressed as dukkha lagyo for sadness, darr tation of the policy was ineffective, and the Mental lagyo for fear and jharko laagyo for irritation. Health Act never came into existence. Several Somatic idioms described as ‘gastric’ for abdom- attempts were made to revise the policy and inal pain and jhum jhum for tingling and numb- ensure effective implementation. The EDCD pre- ness have been manifest in depressed pared a draft in 2018, which has undergone attending healthcare facilities. rigorous consultations with federal, provincial The family provides emotional and financial and local government representatives in mental support and is actively involved in care. Key man- health and is planned to be endorsed through agement decisions are usually made by senior the MoHP. The five key strategies are: family members. Stigma and discrimination towards people with mental illness is a major (a) to ensure the availability and accessibility of problem and mental health literacy is extremely optimal mental health services for all the low, resulting in hiding mental health problems, population of Nepal avoiding treatment and seeking alternative care. (b) to ensure management of essential human Stigma among service providers against people and other resources to deliver mental with mental illness has been identified as one of health and psychosocial services the barriers to mental healthcare. Involving (c) to raise awareness of mental health to patients and caregivers in treatment processes demystify mental illness and reduce asso- and building the capacity of non-specialist service ciated stigma and promote mental health providers can contribute to reducing stigma.8 (d) to protect the fundamental rights of people with psychosocial disability and mental illness Training (e) to promote and manage health informa- tion systems and research in mental health Three-year postgraduate training in psychiatry programmes. (MD Psychiatry) started in 1997 and is now avail- able in 16 institutions. There are five different The MoHP developed the Community Mental post-graduate training programmes, but the Package Nepal, 2074 in 2017 to training curriculum and evaluation process is facilitate implementation of the 1996 National not uniform. There are currently about 45 resi- Mental Health Policy.11 This package is guided dents in psychiatry training. The undergraduate by the principles of integration of mental health syllabus in psychiatry is not nationally standar- into primary care and the WHO Mental Health dised and each university has its own version.9 Gap Action Programme (mhGAP). The MoHP

2 BJPSYCH INTERNATIONAL VOLUME 18 NUMBER 2 MAY 2021 Downloaded from https://www.cambridge.org/core. 02 Oct 2021 at 00:03:09, subject to the Cambridge Core terms of use. has been scaling up nationwide community men- The government should prioritise mental tal health programmes based on this package. health research via academic universities Similarly, the National Health Training Centre and teaching hospitals. of the MoHP has developed four different train- (g) Although community mental health pro- ing modules for building the capacity of non- grammes have been scaled up, there is specialist service providers.12 lack of clinical supervision of trained non- specialist service providers and no regular Psychiatric association supply of psychotropic medications.12 The Psychiatrists’ Association of Nepal (PAN) is non- These need to be ensured for effective profit professional organisation of Nepalese psychia- implementation of mental health services trists established in 1990.9 It regularly organises in primary care settings. annual meetings and educational events. It pub- lishes a biannual peer-reviewed journal (Journal of Psychiatrists’ Association of Nepal). Recently, PAN has Author contributions been active in the national mental health pro- All authors meet all four ICMJE criteria for authorship (design of the fi grammes, policy reforms and advocacy. work, drafting the work, nalapprovaloftheversiontobepublished, and agreement to be accountable for all aspects of the work). The way forward Psychiatric services have seen tremendous devel- Declaration of interest opments over the past decade, such as the None. increased number of mental health professionals, scaling up of community mental health pro- ’ fi grammes, establishment of the country s rst References child and adolescent psychiatry unit, designation 1 Upadhyaya K. Mental health & community mental health in of a focal mental health unit at the MoHP, initi- Nepal: major milestones in the development of modern mental ation of the National Mental Health Survey and health care. J Psychiatrists’ Assoc Nepal 2017; 4:60–7. active engagement of PAN. Despite these 2 Upadhaya N, Luitel N, Koirala S, Adhikari R, Gurung D, Shrestha improvements, the following challenges need to P, et al. The role of mental health and psychosocial support be addressed urgently. nongovernmental organisations. Intervention 2014; 12:113–28.

(a) The budget allotted for mental health is 3 Jha A, Ojha S, Dahal S, BC RK, Jha B, Pradhan A, et al. A Report still low, and there is a need to increase on Pilot Study of National Mental Health Survey, Nepal. Nepal the budget to ensure effective scaling up Health Research Council, 2018. of community-based mental health pro- 4 Suvedi B, Pradhan A, Barnett S, Puri M, Chitrakar S, Poudel P, grammes throughout the country. et al. Nepal Maternal Mortality and Morbidity Study 2008/2009: (b) Lack of awareness on mental health and Summary of Preliminary Findings. Family Health Division, Department of Health Services, Ministry of Health, Government prevailing stigma have been key barriers of Nepal, 2009. to accessing mental healthcare. This demands the formulation and implementa- 5 Marahatta K, Samuel R, Sharma P, Dixit L, Shrestha B. Suicide burden and prevention in Nepal: the need for a national strategy. tion of awareness-raising and anti-stigma WHO South-East Asia J 2017; 6(1): 45. campaigns in communities. (c) There is a need to fill existing vacancies; 6 Kohrt B, Harper I. Navigating diagnoses: understanding mind– body relations, mental health, and stigma in Nepal. Cult Med increase recruitment of psychiatrists; and Psychiatry 2008; 32: 462–91. create positions for clinical psychologists, psychiatric nurses, psychosocial counsellors 7 Chase L, Sapkota R, Crafa D, Kirmayer L. Culture and mental health in Nepal: an interdisciplinary scoping review. Global Ment and community-based psychosocial work- Health 2018; 5: e36. ers in the government healthcare system. (d) The need for subspecialties in psychiatry is 8 Rai S, Gurung D, Kaiser B, Sikkema K, Dhakal M, Bhardwaj A, et al. A service user co-facilitated intervention to reduce mental emerging over time. The government, uni- illness stigma among primary healthcare workers: utilizing versities and medical colleges should envi- perspectives of family members and caregivers. Fam Syst Health sion initiating various subspecialty 2018; 36: 198–209.

programmes in child and adolescent, geri- 9 Koirala N. Psychiatrists’ Association of Nepal – future of atric, addiction and forensic psychiatry. psychiatric services in Nepal – a mission and vision document. J (e) The suicide rate has been a grave concern Psychiatrists’ Assoc Nepal 2014; 2(2): 3–5.

but there is no national suicide registry or 10 Shyangwa P, Jha A. Nepal: trying to reach out to the suicide-prevention strategy in Nepal. A community. Int Psychiatry 2008; 5(2): 36–8. mechanism for suicide reporting and sur- 11 Primary Health Care Revitalization Division. Community Mental veillance and interventions to reduce sui- Health Care Package Nepal, 2074. Primary Health Care cide need to be developed and Revitalisation Division, Department of Health Services, Ministry implemented at a national level. of Health, Government of Nepal, 2017. fi (f) Scienti c research and the generation of 12 Luitel N, Breuer E, Adhikari A, Kohrt B, Lund C, Komproe I, et al. evidence on mental health and illness in Process evaluation of a district mental healthcare plan in Nepal: Nepal is predominantly reliant on NGOs. a mixed-methods case study. BJPsych Open 2020; 6(4): e77.

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