COUNTRY Insight and challenges: mental health PROFILE services in Nepal 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 patient 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 Kathmandu, 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 mother 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. Medications 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 Epidemiology and Disease 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 death 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, headache 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 patients 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