Mental Hospital Lagankhel
Mental Health Nepal
Mental Health in Nepal
Studies in Nepal have shown that 25-30 % of the general population has one or more mental disorders. Approximately 20-25 percent of all outpatients attending primary health care services are showing some sort of mental or behavioral disorders often presented as multiple physical complaints. As most individuals with severe mental disorders and their family members are targets for stigma and discrimination, they hesitate to come forward for appropriate treatment. |
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| Even the patients with neurotic disorders do not like to consult psychiatrists because of the stigma of mental disease. There is inadequate awareness of the problems among decision makers, social leaders and the general population about the mental disorders and their consequences. Table of Contents 1. Major milestones in the Development of modern Mental Health Care 2. Prevalence of Mental Disorders 3. National Mental Health Policy: Past, Present and Future Plans 4. Substance abuse policy 4.1 Control of harm from Alcohol 5. Information and data collecting system on mental health and substance abuse in Nepal 6. Community Mental Health Service: Community based mental health projects 6.1 Family Counseling and Family Intervention in Management of Mental Patients 7. Disability benefits and mental disorders 8. WHO supported mental health activities in Mental hospital, Nepal 9. Conclusion 1. Major milestones in the Development of modern Mental Health Care:
In the last 12 years, one medical institute in the government sector and eight medical institutes in the private sector have come up. Government medical institute ( BP Koirala institute of health sciences Dharan, 1993 ) is in eastern region of Nepal and amongst the private medical college teaching hospitals, three are in the central region ( Kathmandu medical college teaching hospital, 2000 , Nepal medical college teaching hospital, 1997 , Bharatpur medical college teaching hospital, 1998, ), two are in western region ( Manipal medical college teaching hospital Pokhara, 1997 and Bhairahawa medical college teaching hospital 1999) and one in the mid-western region ( Lord Buddha medical college teaching hospital Nepalganj, 2002 ). All these medical college teaching hospitals have most of the specialties including psychiatry. These hospitals are providing psychiatric services. Far- western region of Nepal has no medical college, no well equipped referral hospital and not even a single psychiatrist is working in that region. 2. Prevalence of Mental Disorders 2.1 Epidemiological study Very few epidemiological studies have been done to find out the incidence and prevalence of mental disorders in Nepal. It is estimated that the total prevalence rate of all psychiatric disorders put together exceeds more than 20 % of the total population. The breakdown of the various types of mental disorders and their estimated prevalence in the general population is as follows: (i) Psychosis 1-2 % (ii) Neurosis of all kinds 10 % (iii) Depression 4-6 % (iv) Seizure disorders (epilepsy) 1 % (v) Mental retardation 3-5 % (vi) Alcohol use disorders 3-5 % (vii) Narcotic and other substance use disorders 0.5 % (viii) Others (PTSD, psychogeriatic etc) 1 % Some of the studies carried out in Nepal are quoted here. Shrestha, DM; Pach A; Rimal, PK. (1983); A social and psychiatric study of mental illness in Nepal, Kathmandu. "Door to door survey in a semi-urban setting near Bhaktapur in 1983 found 14.6 % of the population had identifiable mental disorder. This included 2% with severe treatable mental disorders inhibiting the patient from working. This study excluded children under 9 years” “A Nationwide survey of mentally retarded individuals carried out by Shrestha D.M. in 1989 found out the prevalence of Mental Retardation to be 3-5 % of the total population. This condition is a chronic lifelong functionally and socially disabling condition”. Upadhyaya KD, Pol, K (2003); A mental health prevalence survey in two developing towns of western region. J.Nep.Med. Association, vol.42, no.150 ; pp 328-330: “A prevalence survey was done to find out the conspicuous psychiatric morbidity (CPM) in two rapidly developing towns of western region by using Self - Rating Questionnaire (SRQ). Out of 894 people interviewed 773 were selected for analysis. The CPM point prevalence rate of 35.4 % was found. The high prevalence of CPM was most likely due to less stable social structure in the towns in transition.” There has been no national level epidemiological survey on drug use in the country. Information obtained from limited survey reports, police and other law enforcement agencies, treatment centres, NGO’s and key informant personal, estimate about 50,000 drug dependent persons in the country. Main drugs of abuse are heroin, inj buprenorphine, codeine, nitrazepam, cannabis and various combinations of these drugs. About 20,000 of these drug addicts are believed to be intravenous drug users (IDU, s) and 40 % of these IDU’s are said to be HIV infected according to some small scale studies. In 2001 (Dr NM Shrestha, unpublished report), “ a study on alcohol and suicide was done in Kathmandu metropolitan city, the important findings included 31 % of the general population age 12 years and above use alcohol (22 % males and 9 % females), prevalence of alcoholism in the general population is 4.5 % (CAGE) and 5.5 % (Brief MAST), alcoholism among alcohol users was 14.7 % (CAGE) and 17.7% (Brief MAST). Suicide rates in the country was 10.38/100,000 population and in Kathmandu was 6.74/100,000 population it means that the Kathmandu prevalence was 1.5 times less that the national suicide rate.” 3. National Mental Health Policy: Past, Present and Future Plans: Until the 60’s there was no specialist service available for mental disorders in Nepal. The first psychiatrist returned from his overseas studies in 1961 and started a small outpatient department in Bir hospital Kathmandu. Since then the development of modern mental health care has already been mentioned in major milestones. The National Mental Health Policy and Plan has been adopted by His Majesty’s Government in the year 1997. This policy and plan has been formulated keeping in view the magnitude of mental health problems in the country, existing resources both human and material and delivery of health care to the people in the rural areas. This policy has four broad objectives: i) To insure the availability and accessibility of mental health services for all the population of Nepal by integrating mental health services into the general health service system of the country. ii) To prepare human resources in the areas of mental health. iii) To formulate appropriate legislation to ensure the fundamental human rights of the mentally ill in Nepal. iv) To improve awareness about mental health, mental disorders and promote mentally healthy life styles. There have been important developments in the field of mental health, and these have gained momentum in the last a few years. They are: (a) Start of the three post graduate programmes related to mental health like MD in psychiatry, M.Phil in Psychology and diploma in Psychiatric nursing by the Institute of Medicine (IOM). BP Koirala Institute of Health Sciences (BPKIHS) has also started post graduate MD course in psychiatry. National Academy of Medical Sciences (NAMS) Bir hospital is also planning to start MD Psychiatry course in the future. (b) Curriculae of health workers have been revised and common mental disorders like depression, anxiety neurosis, hysteria, psychosis, childhood mental disorders, mental retardation and alcohol and drug abuse have been included. (c) New Mental Health Act (Mental Health Legislation) has been prepared and it is in the Ministry of Health waiting for approval. (d) Medical college teaching hospitals with psychiatric department have come up in the private sector in Kathmandu, Bharatpur, Pokhara, Bhairhawa and Nepalganj. (e) Treatment and rehabilitation centres are available for chronic psychotic patients and drug dependence cases in the non-governmental sector though in a small scale. 4. Substance abuse policy including control of harm from alcohol: There has been no national level epidemiological survey on drug use in the country. Information obtained from limited survey reports, police and other law enforcement agencies, treatment centres, NGO’s and key informant personal, estimate about 50,000 drug dependent persons in the country. Main drugs of abuse are heroin, inj buprenorphine, codeine, nitrazepam, cannabis and various combinations of these drugs. About 20,000 of these drug addicts are believed to be intravenous drug users (IDU, s) and 40 % of these IDU’s are said to be HIV infected according to some small scale studies. The Narcotics Drugs (Control ) Act, 2033 (1976) states that cultivation, production, preparation, manufacture, export, import, purchase, possession, sale or consumption of most commonly abused drugs is illegal (Narcotics 1998, Narcotics 2001). The maximum penalty for drug trafficking is 33 years imprisonment (UNAIDS and UNDCP 2000) His Majesty’s Government of Nepal has got a National Drug Control Policy which was evolved in 1995. This Policy has following goals: “Law enforcement, harm reduction, demand reduction, social support, treatment and rehabilitation, legislative support, international obligations and strengthen institute, organizations/departments/bodies/ officers for implementation of the programme”. The Ministry of Home Affairs is the focal ministry and is responsible for advising the government on policy and for the monitoring and coordination of drug control programmes, projects and activities. Supply reduction through law enforcement, and demand reduction through preventive action, treatment and rehabilitation are the two main operational areas. Treatment and rehabilitation works are mainly done by the NGO, s. There are 10 drug treatment and rehabilitation centres in Kathmandu. They have a capacity of about 200 beds in all for the rehabilitation of drug addicts. Some of them run needle exchange programme and some are working only with HIV positive cases. Centres for harm reduction, treatment and rehabilitation are also there outside Kathmandu valley in Dharan, Biratnagar, Kakervitta, Pokhara and Nepalganj. Mental hospital was running methadone maintenance programme with the support of World Health Organization for methadone in the past. This programme may be restarted if the resources and the trained manpower are available in the near future. 4.1 Control of harm from AlcoholAlcoho l producction, trade and industry: There are 36 large distilleries and five large breweries in Nepal. There are no data available on consumption of informally – produced, home brewed or smuggled alcohol. Beer and spirits production have been rising. Adult per capita consumption of licensed beer and spirits (excluding home and illegal production) in 1996 was nearly 2.5 liters of pure alcohol. There is a substantial amount of home production of alcohol, and drinking is more common than the per capita figures would indicate. Morbidity It was reported in 1997 that 8 % of hospital emergency room cases were alcohol related, while 2 to 10 % of psychiatric admission and out patients had alcohol problems. Economic impact The government derives between 3.2 and 3.5 percent of its total revenue from the alcohol industry. In 1996-1997 this totaled 1480 million Nepalese rupees. Alcohol policies The Hotel Business and Liquor Sale and Distribution Act (1996) prohibit the sale of liquor to anyone less than 16 years of age. The government has no policy designed to curb the production or sale of alcohol. The Liquor Act (1971) requires that anyone producing, selling, importing, and exporting liquor obtain a license to do so, although Clause 7 of this act allows anyone to produce a small amount of liquor without a license. There is a 40 % sales tax and a 25 % income tax on the factory price of total production. As regards the control of harm from alcohol, National Drug Control Policy states “while the tremendous degree of harm caused by illicit drug is taken into serious cognisance that caused by licit substances such as alcohol and nicotine will be considered no less important. Alcohol is generally produced, consumed and accepted as a social norm by some ethnic groups in Nepal. Alcohol users in the villages mainly consume home-brewed alcohol. How much of home brewed liquor is produced annually is not known. In 2001, a study on alcohol and suicide was done in Kathmandu metropolitan city, the important findings included 31 % of the general population age 12 years and above use alcohol (22 % males and 9 % females), prevalence of alcoholism in the general population is 4.5 % (CAGE) and 5.5 % (Brief MAST), alcoholism among alcohol users was 14.7 % (CAGE) and 17.7% (Brief MAST). Suicide rates in the country was 10.38/100,000 population and in Kathmandu was 6.74/100,000 population it means that the Kathmandu prevalence was 1.5 times less that the national suicide rate. Prevalence rate of alcohol use disorders is estimated to be 3-5%. There is no national alcohol control policy and no separate institution for the treatment / rehabilitation of alcohol dependence cases. 5. Information and data collecting system on mental health and substance abuse in Nepal In the 44 item morbidity form, code 30: epilepsy, code 31: mental disorder and code 44: others are there. Data on mental health and substance abuse can only be collected under these codes. This form is used to collect data of new out-patients attending district hospitals, primary health centres, health posts and sub-health posts. Mental disorders reported by all the district hospitals / primary health centres and health posts are just 15000 in the last annual report. This is a very low figure and it is either because of diagnostic difficulties or poor reporting system. A workshop was held on 18th July 2004 with the financial support of WHO to improve the reporting system in mental health. Six diagnostic categories namely (i) Depression (ii) Acute psychotic disorders (iii) Chronic psychotic disorders (iv) Anxiety disorders (v) Alcohol use disorders and (vi) Mental retardation have been recommended to add in the morbidity form. Mental health training to the health personnel who see outpatients will also be needed to diagnose the above mentioned mental disorders. Data from the referral hospitals, teaching hospitals, private sector hospitals and NGO run hospitals if included in the annual report of the Department of health, burden of disease will be much more clear. Such report is expected to be available from next year. 6. Community Mental Health Service: Community based mental health projects Nepal has a population of 23.15 million people; and primary health care is provided at the community level by sub-health posts, health posts, primary health centres and the district hospitals. Sub-health posts and health posts and some of the primary health centres are run by paramedical staffs. District hospitals and some of the primary health centres are manned by medical officers (medical graduates). District hospitals have out-patient and inpatient facilities, they serve as the referral point for the sub-health posts and health posts but these hospitals do not provide specialist service. General health care service is integrated in Nepal so all these centres provide both curative and preventive health care. As mental health service is not integrated, mental health is not an integral part of primary health care. There are no community care facilities for patients with mental disorders. Regular training of primary health care professionals is not carried out in the field of mental health. In light of these limitations in services, a pilot community mental health programme was started by United Mission Nepal (UMN) in Lalitpur district in 1984 to know the feasibility of integrating mental health care into the existing health structure. This project provided community mental health service through the existing health care system in one of the health post in Lalitpur district. It was found that psychiatric disorders commonly present to primary health care in Nepal, and that the presenting symptoms were usually somatic. The treating health workers were largely unable to recognize and diagnose this significant group of patients. If these health workers were given training in mental health for common mental disorders, they were able to diagnose common mental disorders. So this model was replicated in Morang District in 1991 and Kaski district in 1992. The main aim of community mental health programme was to integrate mental health service into the existing health care system. The western region community mental health programme (WRCMHP) was developed into four phases. The first phase covered only one district Kaski (1992-1993 ), in second, third and fourth phase, programme was extended to several districts of that region. Training of health workers including refresher training, provision of specially designed patient record cards, essential drugs, mental health educational materials and supervision and referrals were the main activities. Community mental health programme in western region aims to develop a model to integrate mental health service in existing health care system. It has mainly 3 components: (i) capacity building in mental health of health workers working in government health system (ii) awareness raising activities and (iii) research in mental health. An Impact Study of the Community Mental Health Programme in Western Region, Nepal was recently completed by Mental Health Programme UMN/CMC. It was aimed to evaluate outcomes of the community mental health service that has been operating for more than eleven years in selected districts of western region of Nepal. The study followed experimental-control study design and used both quantitative and qualitative approach to analyze data. This study revealed that ” trained health staff were able to maintain mental health knowledge and skills effectively, …trained health workers were more efficient in diagnosing and treating each case than the control group. The diagnosis and treatment pattern of health workers in the experimental group had a high degree of agreement with psychiatrist regarding diagnosis and treatment, which further proved the effectiveness of training to health workers. Qualitative information from health workers revealed that mental health service is effective in strengthening capacity of health workers, increasing availability of mental health services in community and in reducing the stigma of mental illness” Findings of the study proved mental health services in the primary health care system were possible if mental health training to health workers and supervision were provided. Health workers were skillful in identifying and treating mental patients. Such programme is useful in reducing the stigma of mental illness in the community. 6.1 Family Counseling and Family Intervention in Management of Mental Patients in Kathmandu Metropolitan City Conducted Jointly by Mental Hospital, Lagankhel and Community Mental Health Center (CMHC) (Unpublished Report) Research conducted in year 2002 in Kathmandu Metropolitan Area by CMHC found “30 % people suffering from various mental problems. Due to the social stigma, risk of discrimination and avoidance, general people do not like to expose the mental problem in public. General people regard only psychotic cases as mental problems and remaining mental disorders are not taken as mental problems. Except for severe psychotic disorder and mental retardation, family members tried to hide the other problems. People think that mental illness is incurable. Community people denied identifying neurotic disorders, drug users and alcoholics as mental patients. The family members regard medication as complete treatment. They did not know counseling as therapeutic model. They expect the patient to behave like normal people. The lack of knowledge, social stigma and avoidance are interfering in the recovery process of the patient. Family itself suffers from the problem. To overcome these problems, Family intervention with family counseling was launched in different wards of kathmandu city. During the family intervention outreach programme, 236 identified patients were served. Among them, majority were males (64.86 %), majority were of 31-60 years age group (43.24 %), unmarried (49.73 %), average class (41.08), Mood disorders (17.30 %), Schizophrenia 14.59 % ) and Mental retardation (28.11%). This programme made community people aware of mental health and importance of psycho-social intervention. It reduced the avoidance of mental patients and fear with the patient. It also helped in maintaining social support and self- esteem of patient’s family. It improved the coping techniques, reduced stress of the family members and improved the condition of mental patients at home.” The study team recommended: Family intervention programme to be continued, free check-up by psychiatrist and free medication, supportive advocacy programmes of awareness on mental health in community, education programmes on illicit drug use, alcoholism and child development, day care centres for schizophrenic patients at different locations, day care centres for mentally retarded patients, community based drug and alcohol detoxification centres, management programme of street mental patients and work oriented budget /allowance. 7. Disability benefits and mental disorders: Chronic mental illness has been classified as one of the mental disabilities and these patients have equal rights as other disabilities according to the disability Act. 8. WHO supported mental health activities in Mental hospital, Nepal Activities supported were training of medical doctors, paramedical staffs and nursing staffs at district hospitals/ primary health centres on mental health issues. Provision of equipments like Electroconvulsive therapy machine (ECT), logistic supports (computers, furniture’s etc), psychiatric journals and books, supply of methadone and support for small scale research work are some other activities. In recent years WHO support on awareness raising programmes like radio and television programmes on mental health issues, distribution of pamphlets, counseling activities, and preparation of training materials (Manuals) for different level of health workers was available. As awareness about mental health is very low in Nepal, these awareness raising programmes are expected to change the perception about mental patients. 9. Conclusion In a population of about 23.15 million human resources in mental health are limited. There are approximately 300 psychiatric beds in the country. Implementation of National Mental health policy and Plans is yet to start. There is no separate Mental Health Legislation in the country though its draft is in the Ministry of Health. Primary mental health care is not available at the health posts, primary health centres and district hospital levels. Even in many referral hospitals, psychiatrists are not available. Common psychotropic and antiepileptic drugs are not in the essential lists of drugs in primary health care level. There is general lack of awareness about mental disorders. Stigma attached to mental disorders and epilepsy discourages patients and their family members to come forward for treatment. Political commitment to improve the mental health service of the country, implementation of national mental health policy and integration of mental health service into the existing health service network is necessary to improve the mental health service. Mental health legislation is essential for complementing and reinforcing mental health policy and providing a legal framework. Stigma and discrimination associated with mental disorders impact negatively on access to care and on the social integration of people suffering from such disorders. Ignorance or lack of proper knowledge is the root cause of all stigmas. Awareness raising programme in mental health, good care of mental patients, rational use of treatment and involvement of family members in the treatment will help to reduce stigma of mental disorders. [This text is taken from a presentation by Dr Kapil Dev Upadhyaya at the Nepal Mental Health Policy, Strategy and Plan of action workshop on 24 Aug 2004, Kathmandu.] |
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