Nepal’s mental health mess

Arun Poudel

Arun Poudel

Nepal’s mental health mess

There seems to be increased awareness about the paucity of mental health services in Nepal, especially after the 2015 earthquake. But neither are there enough mental health professionals nor a system to ensure quality of their services

With roughly 0.22 psychiatrists and 0.06 psychologists for every 100,000 people, Nepal is woefully underprepared to meet its growing mental health challenges. The state’s investment in mental health is dis­mal—under a percent of the total health budget. The result: up to 90 percent Nepalis with mental health problems never get professional help. Even the little manpower Nepal has in mental health may not be up to the standard in the absence of a regula­tory body certifying their qualifications and credentials.

“Without a reliable professional body regulating mental health professionals, we cannot ensure the quality of the services they provide,” says Dr. Mita Rana, a clini­cal psychologist and associate professor at IOM’s Department of Psychology and Mental Health. “Baffles me how such an important issue has been taken so lightly!”

How many mental health pro­fessionals are there in Nepal? It is hard to say. What can be said for sure is that there are far few of them. Roughly, there are 0.22 psychiatrists and 0.06 psychologists for every 100,000 peo­ple (see box below), respectively. As a result, around 90 percent peo­ple needing mental health treatment in Nepal don’t get it.Shova Rijal (name changed) of Dhapasi returned to Kathmandu from New York a year ago. Her job as an executive at a stockbroking firm in New York was taxing and she used to book a session with her counselor when­ever she felt stressed out. But she couldn’t do that in Nepal. When she heard of a meditation retreat in a mon­astery next to Swayambhu, she readily joined.

“You know it’s not easy to find a professional counselor here,” says Rijal. “I did a little research, and found nothing convincing.” In the US, she paid $400 for an hour-long session. She thought that was expensive but worth it nonetheless. The four-day retreat in Kathmandu helped her a lot, as she later shared. But it may not be as helpful to oth­ers. As different people have differ­ent mental health conditions, their needs vary.

Jagannath Lamichhane, a men­tal health expert and chairperson of Juggernaut Mindset, thinks that “the non-stigmatizing and accom­modative nature of our society helps people deal with psychological prob­lems to an extent”. He thinks the cul­ture of going to temples and meeting spiritual teachers provides psycho­logical healing, but there may be situations when people need clinical support. More so when the situation has already gone out of hand.

For Lilu Sharma, an engineer by profession, a six-day Art of Living course and then a 10-day Vipassana meditation retreat in Kathmandu were helpful. But the stress of having to look after her alcoholic father, ailing mother, and estranged broth­er, both in terms of time and mon­ey, required something more. More than that, she looks after 114 young men and women aged 16-26 at four hostels she runs in Kathmandu. She counsels these people on all sorts of topics.

What she is doing is more than an ordinary person can handle, much less a single woman in her 20’s. So she thought it would be wise to visit a counselor. “Sometimes, the pressure of having to do everything requires me to go and seek profes­sional help,” she shares. “This helps with my own stress and also enables me to help others.”

Pros and semi-pros

Dr. Kapil Dev Upadhyaya, a senior psychiatrist and consultant at the Thapathali-based Center for Men­tal Health and Counselling-Nepal, stretches his schedule a little to listen to Sharma, as he knows how import­ant it is. Himself a meditation prac­titioner, Upadhyaya also thinks our social and spiritual systems naturally support mental well-being. Still, there is a need for professional help, just as Sharma sought.

While it’s beyond doubt that more mental health profession­als are needed, ensuring their qual­ity is as important. There are very few academic programs in the coun­try to train professional counsel­ors. And there is no mechanism to look after the quality of training.

Tribhuvan University’s Institute of Medicine (IOM) provides an MPhil degree in clinical psychology that enables one to be a licensed clinical psychologist. Likewise, TU’s Central Department of Psychology (CDP) provides two-year master’s degree in psychology and one-year certifi­cate on counseling. The IOM MPhil program started in 1999, but the total number of graduates is still under three dozens in the highly-compet­itive program. The country of near­ly 30 million as such has just over 30 clinical psychologists offering their expertise.

CDP graduates may choose to be psychosocial or school counselors. But they cannot be a registered counselor due to the absence of a regulatory body. Not being affiliated may also mean lack of accountabili­ty. The IOM graduates, on the other hand, can register at the National Health Professional Council (NHPC).

Medical doctors have a well-estab­lished medical council that accredits them after a comprehensive written test. But sans a standard procedure, anybody with a clinical psychology degree from any university can reg­ister at the NHPC. That worries Dr. Mita Rana, a clinical psychologist and associate professor at IOM’s Department of Psychology and Mental Health.

“Without a reliable professional body regulating it, we cannot ensure the quality of mental health services being provided,” says Rana. “Baffles me how such an important issue has been taken so lightly!”

Some non-government organi­zations offer short-term counsel­ing training. But these are only seasonal and tailor-made pro­grams ranging from one week to few months in duration. Both Lamichhane and Dr. Rana are skeptical of the quality of these programs. The trainees are either NGO workers or are later employed by them. Their skills may not be of much help to most sufferers of mental health problems.

Hope amid despair

One reason Nepal has few mental health professionals is low pay. Counselling in par­ticular is time-consuming. The medical doctors hardly spend 2-3 minutes on an out-patient in Nepal. In an hour, a busy doctor sees as many as 30 patients: the more patients you see, the more money you make. But clinical psy­chologists do not have that luxury. Sometimes they may have to spend hours with a single patient, limiting their scope of payment.

Dr. Rana, who sees patients at Teaching Hospital, spends an hour with a patient on average. “It’s a delicate process. We have to spend time with the patients, and closely listen to them. Only then can we help them.”

She also does part-time consul­tancy at the Gyaneshwor-based Himal Hospital. In her three hours at Himal, she can see only three patients. A patient pays Rs 800 per session at the hospital, compared to $400 (Rs 45,000) Rijal paid in New York. “Despite the pay, you cannot neglect the need for more profes­sional mental health services,” Dr. Rana asserts.

The need for psychological coun­seling was particularly high after the 2015 earthquakes when many peo­ple suffered mental trauma, accord­ing to Dr. Upadhyaya. Perhaps this realization led to Nepal hosting the first International Conference on Mental Health in February 2018. One of the conference recommendations was to ‘improve the technical capac­ity and skills of health profession­als working at all levels of mental health care’.

But no improvement toward that end is in sight. There is hope though. The Nepal Health Research Council, a body under the Ministry of Health and Population, has started a Nation­al Mental Health Survey project that is expected to give a ‘clear national picture of the prevalence of mental disorder and unmet need for ser­vices’. The report, due in 2021, could potentially be a game-changer for mental health in Nepal

Mental health stats

•Government spending is less than 1 percent of its total healthcare budget on mental health.
• There are 0.22 psychiatrists and 0.06 psychologists per 100,000 people.
• Mental health services are concentrated in the big cities.
• There are approximately only 50 psychiatric clinics and 12 psychological counseling centers.
• An estimated gap between treatment and magnitude of mental health problems is over 85 percent.
• There are estimated 1.5 beds per 100,000 people across the country for mental health patients.
• Suicides among women of reproductive age increased from 22 per 100,000 in 1998 to 28 per 100,000 in 2008.
• Only 2 percent of medical and nursing training is dedicated to mental health.
Source: Health Research and Social Development Forum (HERD), 2016

Where to seek help?

Only a few facilities in Nepal provide psychological support (psychiatrist or clinical psychologist) for those with mental health problems, including the ones mentioned below. The list is not comprehensive; we hope it can be a starting point though.
1. Center for Mental Health and Counselling-Nepal (CMC-Nepal), Thapathali (01-4102037, 4226041)
2. Rhythm Neuropsychiatry Hospital and Research Center Pvt Ltd, Ekantakuna (01-5000700, 5000711)
3. Mental Hospital, Lagankhel (01-5522278, 5522266)
4. Teaching Hospital, Maharajgunj (01-4412303, 4412505, 4412605)
5. Patan Hospital, Lagankhel (01-5522278, 5522266)
6. Kathmandu Medical College, Sinamangal (1-4242121, 4242015)
7. Private hospitals [Himal (01-4415076), Om (9802076225), Norvic (01-4258554), Mediciti (01-4217766), Metro (01-4721514, and others]
8. BPKIHS Dharan (025-525555)
9. Manipal Teaching Hospital, Pokhara (061-526416/17/18/19)