Psychiatric Bulletin (2007) 31: 348-350. doi: 10.1192/pb.bp.107.014571
© 2007 The Royal College of Psychiatrists
Nepalese psychiatrists’ struggle for evolution
Arun Jha, Chairman
Psychiatry Section, Nepalese Doctors’ Association (UK) and
Consultant Psychiatrist, Hertfordshire Partnership NHS Trust, Logandene Care
Unit, Ashley Close, Hemel Hempstead, Hertfordshire HP3 8BL, email:
arunjha{at}hotmail.co.uk
Declaration of interest
None.
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Introduction
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Nepal has a short and slowly developing history of psychiatry. Recent
political turmoil has crippled Nepalese healthcare in rural areas. Although
the final quarter of the 20th century saw some development of psychiatric
services in Nepal, the majority of Nepalese people remain deprived of such
services even today. There is no national health programme or Mental Health
Act. Psychiatric services are hospital based and most are centralised in the
capital. Nepalese psychiatrists need urgent help, but they have been unable to
form a strong professional body. This report presents the historical
background, current state of affairs and suggestions for modernising mental
health services in Nepal.
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The country
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Nepal is a small Himalayan kingdom (desperate to be a republic) sandwiched
between India and China. The United Nations classifies Nepal as one of the
least developed countries in the world, with a per capita income of just
£150. Nearly two-fifths of the population lives on less than 90p a day.
It is predominantly a rural country where only 15% of the population live in
urban areas. Less than 3% of gross domestic product is spent on the healthcare
system and only 0.8% of the healthcare budget is spent on mental health.
Nepalese psychiatrists and other mental health professionals deserve a huge
round of applause for hosting the second international conference of the South
Asian Association for Regional Cooperation (SAARC) Psychiatric Federation
(SPF) in Kathmandu on 17-19 November 2006. Established in 1985, the SAARC is a
political and economic organisation of (currently) eight countries in southern
Asia. The theme of the conference was ‘Social conflicts and mental
health challenges to psychiatrists’. Delegates from the neighbouring
countries had their stories to tell, ideas to share and papers to present, but
Nepalese psychiatrists were conspicuous by their absence at the podium.
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Mental health problems
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Nepal is a rural country. The majority of its population depend on
agriculture and farming. The complete absence of a social welfare net is a
major obstacle to the development and delivery of mental healthcare. The
approximate financial burden that falls on a family when one of its members
becomes mentally ill is around 25 000 Nepalese rupees (equivalent to nearly
£200) per year. Most people think that mental illness means becoming
crazy or lunatic, being possessed by spirits or losing control of oneself
(Regmi et al, 2004).
Although healthcare professionals are becoming more aware of mental health
problems (Shyangwa et al,
2003), the majority of rural Nepalese people still believe that
mental illness is caused by bad fortune.
There are no national morbidity data for mental illness either in primary
or secondary care. The prevalence of mental disorders in Nepal apparently does
not differ from that of other countries in the south Asia region. According to
Dr Kan Tun (personal communication, 2006), the World Health Organization (WHO)
representative to Nepal, around 1% of the population has severe mental illness
and 10-20% milder mental health problems. A survey of two developing towns in
western Nepal in 1998 revealed a high point prevalence (35%) of
‘conspicuous psychiatric morbidity’
(Upadhyaya & Pol, 2003).
About 2% of people with that degree of morbidity have been reported to suffer
from incapacitating illnesses requiring continuous support. The current
situation would certainly be different as a decade-long Maoist insurgency has
caused immense social upheaval.
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Janakpur Mental Health Camp
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Holding ‘mobile camps’ to assess and treat patients in areas
without specialist medical facilities is a common means of offering medical
help in the deprived communities of low-income countries.
‘Ashadeep’, a non-governmental organisation, provides a similar
service outside Kathmandu by running free monthly mental health clinics in
three districts. In January 2006, the psychiatry section of the Nepalese
Doctors’Association (UK) organised a 3-day mental health camp at
Janakpur, a provincial town in south-east Nepal, in collaboration with the
local Red Cross Society. There is no mental healthcare for a population of
over 1 million in Janakpur province. The nearest psychiatric unit is a 4-hour
drive away. There were five qualified psychiatrists including the author. The
event was advertised by national and local media.
Total number of patients seen at the camp was 290, double the expected
number. Data for only 202 patients were available for analysis. The majority
of patients were female; there were only 90 males. The age ranged from 4 to 89
years. Table 1 describes the
common clinical diagnoses and their frequency at the camp. The data are close
to those reported previously (Nepal et
al, 1986). A high proportion attending with epilepsy and
headache (about one-fifth) simply reflects the absence of a neurological
service in a country where there is no concept of family physicians.
A 17-year-old girl was brought to the camp by her relatives. She exhibited
classical signs of an acute manic episode. She was admitted to a medical ward,
tied to the cot and treated with up to 20 mg haloperidol intra-muscularly over
a period of 24 hours. The following day she became sedated and dehydrated,
requiring intravenous fluid. As there is no psychiatric follow-up care
available in that province, her family would have to travel several hours by
public transport for psychiatric review. This scenario is not uncommon in
Nepal.
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Healthcare and mental health services in Nepal
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Healthcare in Nepal is delivered through hospitals in the urban areas, and
health centres and health posts in the rural areas. There are over 3200
physicians in Nepal - 4 per 100 000 population. During the decade-long
Maoist-armed insurgency, hundreds of community health posts have been
destroyed, dozens of healthcare workers have lost their lives and many fled
their posts. Unfortunately, health services in Nepal are organised in such a
complex and bureaucratic manner that reforming the Nepalese National Health
Service would require a total culture change.
The situation of mental healthcare in Nepal is worse than in its
neighbouring countries (for example Sri Lanka, which has a comparable
population and an equally turbulent history, but a high health status;
Mendis, 2004). In 1986, there
were only 10 psychiatrists in Nepal. In the past 20 years, the number has
trebled to 30 but is still less than in Sri Lanka which has a smaller
population (Table 2). In both
countries, most psychiatrists working for the government or for a university
have a lucrative private practice after their contractual hours. Almost all
patients prefer to seek private consultation for both general medical and
psychiatric services as long as they can afford to do so financially. The most
remarkable difference is in the number of psychiatric nurses, over 400 in Sri
Lanka and only 18 in Nepal.
Unfortunately, almost all mental health professionals and services are
based at urban centres, mostly in the capital, Kathmandu
(Table 3). Although private
medical schools with an attached psychiatric unit are being opened all over
the country, the entire process is patchy and unplanned.
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The way forward
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The number of psychiatrists and other mental health professionals has been
steadily growing in Nepal since the author came to the UK in 1986 for higher
psychiatric training. A few extra psychiatric wards and postgraduate
psychiatric training programmes have been added during the past 20 years but a
lot remains to be done. To improve mental healthcare in Nepal, efforts should
be focused on raising awareness, making existing services available to the
general public and monitoring mental health delivery systems
(Regmi et al, 2004).
Nepalese psychiatrists have to start talking to each other and to their
neighbours and colleagues across the world, not just to satisfy their personal
ambitions but also to address the grossly neglected mental health programme of
their country. Nepalese psychiatrists living in the UK are conscious of their
obligation towards Nepal, and are determined to turn the tide of brain drain
into a gentle flow of brain circulation.
To maintain their morale and motivation, they will have to set up research
projects. Alternative routes to healing need to be identified to suit local
needs. Recent advances in psychiatry, as reflected by research and practice in
the Western world, cannot be applied directly to meet the mental health needs
of the non-Western world. George Hsu
(2004) suggests that some of us
in the low-income countries should make an effort to channel our research into
four main areas: rehabilitation of those with chronic mental illness;
treatment of major depression by primary care physicians; developing a more
culturally acceptable form of psychotherapy; and reducing stigma associated
with mental illness. Non-governmental organisations such as the South Asia
Forum on Psychiatry and Mental Health and the Nepalese Doctors’
association (UK) are anxious to help Nepalese psychiatrists.
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Acknowledgments
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I thank the Nepalese psychiatrists Dr Pramod Shyngwa, Dr Shailendra
Adhikary, Dr C. P. Sedain and Dr Ranjan Thapa as well as the physicians Dr
Gaurang Mishra and Dr Vijay Kumar Singh, and all the Red Cross staff for their
help at the Janakpur Mental Health Camp.
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References
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GEORGE HSU, L. K. (2004) International psychiatry - an
agenda for the way forward. International Psychiatry, issue 4
, 5-6.MENDIS, N. (2004) Mental health services in Sri Lanka.
International Psychiatry, issue 3, 10
-12.
NEPAL, M. K., GURUNG, C. K., JHA, A. K., et al
(1986) First 156 patients of a new psychiatric outpatient
department (OPD): socio-demographic profile and diagnostic status.
Journal of Nepal Medical Association,
24, 7-19.
REGMI, S. K., POKHREL, A., OJHA, S. P., et al
(2004) Nepal mental health country profile.
International Review of Psychiatry,
16, 142
-149.[CrossRef][Medline]
SHYANGWA, P. M., SINGH, S. & KHANDELWAL, S. K.
(2003) Knowledge and attitude about mental illness among nursing
staff. Journal of Nepal Medical Association,
42, 27-31.
UPADHYAYA, K. D. & POL, K. (2003) A mental health
prevalence survey in two developing towns of western region.
Journal of Nepal Medical Association,
42, 328
-330.
Top
Introduction
The country