global challenges of mental health services scenario in nepalr

Chandra Prasad Sedain (MBBS,MD) Associate Professor Department of Psychiatry Chitwan Medical College Bharatpur-10, Nepal Email-drcpsedai@yahoo,com More than 85% of the world's population lives in 153 low-income and middle-income countries . Although country-level information on mental health systems has recently become available, it still has substantial gaps and inconsistencies. Most of these countries allocate very scarce financial resources and have grossly inadequate manpower and infrastructure for mental health. Manyof these countries also lack mental health policy and legislation to direct their mental health programmes and services, which is of particular concern in Africa and South Asia. Different components of mental health systems seem to vary greatly, even in the same-income categories, with some countries having developed their mental health system despite their low-income levels. These examples need careful scrutiny to derive useful lessons. Furthermore, mental health resources in countries seem to be related as much to measures of general health as to economic and developmental indicators, arguing for improved prioritization for mental health even in low-resource settings. Increased emphasis on mental health, improved resources, and enhanced monitoring of the situation in countries is called for to advance global mental health. The care of people with mental and brain disorders is a growing public health concern. These disorders are highly prevalent and exact a high emotional toll on individuals, families, and society. Worldwide, community-based epidemiological studies have estimated rates of lifetime prevalence of mental disorders among adults ranging from 12.2% to 48.6% and 12-month prevalence rates ranging from 8.4% to 29.1% (1). These rates do not include neurological conditions affecting the brain (1). WHO (2) has estimated that approximately 450 million individuals worldwide suffer from neuropsychiatric disorders in their lifetime. Mental disorders are not only highly prevalent medical conditions but they are also highly disabling. Measured by years lived with disability and by premature death in disability-adjusted life years (DALYs), psychiatric and neurological conditions accounted for over 13% of the global disease burden in the year 2001 (3). When compared with 1990, the contribution of neuropsychiatric disorders is expected to increase to almost 15% by the year 2020 (4). Among individuals age 15–44, unipolar depression is the second leading contributor of DALYs, with alcohol-related disorders, schizophrenia, and bipolar disorder among the top 10 disorders. Approximately 33% of all years lived with disability (YLD) are imputed to neuropsychiatric conditions. Of the 10 leading causes of YLD in the world among individuals of all ages, four are psychiatric conditions, with unipolar depression being the leading cause (2). Among individuals between the ages of 15 and 44, panic disorder, drug use disorders, and obsessive–compulsive disorder (OCD) were included in the top 20 disorders. Mental disorders are projected to increase to 15% of the global disease burden and major depression could become the second leading causes in the disease burden after ischemic heart disease. Mental disorder causes extensive disabilities in rich and poor countries alike and is increasing. The global burden of study, has therefore, been an eye opener and mind opener for public health.Mental disorders have a large impact on individuals, families and communities. Individuals suffer the distressing symptoms of disorder. They also suffer because they are unable to participate in work & leisure activities, often as a result of discrimination. They worry about not being able to shoulder their responsibility towards family and friends and are fearful of burden for other. It is estimated that one in four families has at least one member currently suffering from a mental disorder. These families are required not only to provide physical and emotional support, but also to bear the negative impact of stigma and discrimination present in all parts of the words. The burden on families ranges from economics difficulties to economical reactions to the illness, the stress of coping with disturbed behavior, the disruption of household routine and the restriction of the social activities. In addition to the direct burden lost opportunities have to be taken into account. Families in which one member is suffering from a mental disorder make a number of adjustment and compromises that prevent other member the family for achieving their full potential in work, social relationship and leisure. These are the human aspects of the burden of mental disorders, which are difficult to assess and quantify, they are nevertheless important. Families often have to set aside a major part of their time to look after the mentally ill relative, and suffer economic and social deprivation because he or she is not fully productive. There is also the constant fear that recurrence of illness may cause sudden and unexpected disruption of the lives of family members. The impact of mental disorders on community is large and manifold. There is the cost of providing care, the loss of productivity, and some legal problems. In part, the excess disability due to mental disorders is a result of their early age of onset (1). The magnitude of this burden also results from the fact that only a minority of individuals with these disorders ever receives treatment in the specialized mental health care system or in the general health care system (5); initial treatment is frequently delayed for many years (6). Numerous reasons have been imputed. These include: failing to seek help because the problem is not acknowledged, perceiving that treatment is not effective, believing that the problem will go away by itself, and desiring to deal with the problem without outside help (7, 8). In addition a lack of knowledge about mental disorders and stigma remain major barriers to care (9, 10). Factors that are direct barriers to care also preclude treatment, including financial considerations (11), issues of accessibility, as well as limited availability or lack of availability of services in many countries or for some populations (12). In 2011, the World Health Organization estimated a shortage of 1.18 million mental health professionals, including 55,000 psychiatrists, 628,000 nurses in mental health settings, and 493,000 psychosocial care providers needed to treat mental disorders in 144 low- and middle-income countries.. According to World Health Organization figures, in any country including ours, one percent of the population suffers severely incorporating mental disorders. If we project these figures in our country, there would be some two hundred and fifty thousands of severely mentally ill and ten times that number (some twenty five lakhs) of mildly ill persons. It is also noteworthy that nearly 15-20% of people who seek medical help in primary health centers, general hospital or private clinics, have mild mental disorders. But most of them are not aware of it. They think and believe that they have some physical illness. Mental disorders are common, universal affecting people of all counties and societies, individuals at all ages, women and men, the rich and the poor, from urban and rural environments. • Surveys conducted in development as well as developing countries have shown that during their entire lifetime, more than 15% of individuals develop one or more mental disorders. • Mental disorders are present at any point in time in about 10% of the adult population. • One in every four families is likely to have at least one member with a mental disorder. • Mental disorders are common affecting more than 25% of all people at some time during their lives. • Overall prevalence of mental disorders are found to be about the same among men and women. The severe mental disorders are about equally common with the exception of depression, which is more common among women and substance use disorders, which are more common among men. • Mental disorders are common among patients attending primary health care settings. Studies have clearly demonstrated that a substantial proportion (25%) of all patients in these setting have a mental disorder. The most common diagnoses in primary care setting are: - Depression - Anxiety - Substance abuse These disorders are present either alone or in addition to one or more physical disorders. These disorders are no consistent difference in prevalence between developed and developing countries. • 1 in 20 people under the age of 65 suffers from Dementia; this shoots up to 1 in 5 over the age of 80. History of mental health services in Nepal The Kingdom of Nepal is situated in the heart of Asia, between its two big neighbors China and India. Nepal is home to several ethnic groups. The majority of the 27 million population reside in the countryside (13). Although figures on many of the health and socio-economic indicators are non-existing, some existing ones show gradual improvement over the years. However the figures for illiteracy and infant mortality are still one of the highest in the world. As per GDP, and population living below the poverty line and per capita income, Nepal still remains one of the poorest countries in the world. Despite this, it provides shelter to thousands of Bhutanese refugees in its land. Frequent natural disasters and recent violent conflicts in Nepal have further added hardship to life. Less than 3% of the national budget is allocated to the health sector. Mental health receives insignificant attention. There is no mental health act and the National Mental Health Policy formulated in 1997 is yet to be fully operational. Mental ill is not much talked about because of the stigma attached. The roles of the legal & insurance systems are almost negligible. The financial burden rests upon the family. The traditional/religious healing methods still remain actively practiced, specifically in the field of mental health (14). The service, comprising little more than four-dozen psychiatrists along with a few psychiatric nurses and clinical psychologists (mainly practicing in modern health care facilities) has started showing its impact—however this is limited to specific urban areas. The majority of the modern health care facilities across the country are devoid of a mental health facility. The main contextual challenges for mental health in Nepal are the provision of adequate manpower, spreading the services across the country, increasing public awareness and formulating and implementing an adequate policy. History of mental health services in Nepal is not long. Mental health services in Nepal remained unknown till 1961 AD. First psychiatric OPD services were started in 1961 in Bir hospital, Kathmandu.A five-bedded in patients in the same hospital in 1965, which was further extended to 12 beds in 1971. In 1972, a 10 bedded Nero psychiatric unit was established in the a Royal Army Hospital was separated, which was then shifted into the Lagankhel, Patan and it has got 50 beds at present. T.U. Teaching hospital was established in Maharajgunj, Kathmandu in 1983 where psychiatric OPD services started in February 1986. It was followed by addition of 12-bedded psychiatric patient units in December 1987.During 1983-84 a number of non-government organization were started. Nepal's own community mental health service came into existence following Shresth et al, (1983) report. Following this survey, training was arranged for health assistants and paramedical in mental health in around Bhaktapur. This led to setting up of satellite mental health clinic in Bhaktapur. United Mission to Nepal (UMN) community mental health program was started in 1984 and stated a district program in Lalitpur. In 1989, the Department of Psychiatry of TU Teaching Hospital stared the Mental Health Project by launching community mental health program in seven districts of Nepal. There was no training facility for psychiatrists, clinical psychologists and psychiatric nurses in Nepal, before 1997. In the 1997 April, there full time residential MD psychiatry training program was started in the Department of Psychiatry, TU Teaching Hospital, Institute of Medicine, Kathmandu. In 1998 April, two years M. Phil in clinical psychology course was started in TUTH, Institute of Medicine. The Diploma Nursing Program was started in Nursing Campus, Maharajgunj, and Institute of Medicine. MD Psychiatry training program is also started in BPKIHS, Dharan, mental hospital Kathmandu and few private medical college of Nepal. Chitwan medical collage which is one of them, located centre part of the country providing good psychiatric services from starting time and also has lunched diploma psychiatric nursing programme. It also has 25 beded in door services. Many private hospitals also are available for treatment of mentally ill people. Though there are no psychiatric social workers in Nepal, efforts are being made to start the psychiatric social worker training in the country. The weaknesses of mental health system in Nepal are: • Financial constraints • Only one Mental Hospital • Mental health services are not easily available • Stigma around mental health • Poor infrastructure • Limited number of human resources • No mental health legislation • Poor mental health information system • No separate division for mental health under the ministry of health • No developed community mental health services • No facility for rehabilitation of chronic mentally ill people Strengths of the mental health system in Nepal are: • Country has national mental health policy • Good network within the general mental health can be integrated • General increase in awareness of mental health in general population • Increasing number of people seeking treatment in the mental health institution • Available of psychotropic medicines • Private medical college and NGOs are providing psychiatric services. • Good family system, which takes responsibility to their sick family member at home. • Member of world psychiatric association (WPO). In Nepal mental health policy was formulated and adopted by his Majesty's government of Nepal in 1996. The components of minimum mental health policy include: • To ensure the availability and accessibility of minimum mental health service for all the population of Nepal. • To prepare human resources in the area of mental health. • To protect the fundamental human rights of the mentally ill. • To improve awareness about the mental health. Facts about the mental illness in the scenario of Nepal 1. Organic Psychiatric disorders in many occasions are associated with visual hallucination and alteration of sensorium in day and night. Symptoms worse at night. 2. History taking is usually not sufficient with people taking alcohol or drugs. In many occasions get wrong history from patients. They take more quantity but give history of less quantity. 3. In Nepal there is many unqualified drug rehabilitation centre opened with absence of medical person. They bring different medicine from market illegally and give to patients which is very dangerous. In many occasions alcoholic patients give history of fainting attack rather than alcohol abuse. Many alcoholic patients hear voices as schizophrenia. 4. Taking cannabis is danger for health. It increases the risk of schizophrenia. Habit of use of drugs and alcohols leads to other psychiatric disorder like anxiety disorder, depression etc. 5. Schizophrenia is most severe types of Mental illness need to treat long duration minimum 2 year, sometimes 5 year and longer than that. 6. Depressive disorder is commonest psychiatric disorder, life time prevalence 15-25℅, almost double on female than male. Two third of patients with depressive disorder difficult to diagnose many more different clinic & hospital to get rid of their problems & finally reach to psychiatrist. In the context if Nepal depression in female is due to poor relationship in between couple (husband & wife).On many occasion husband is alcoholic and wife develops depression. In Nepal many depressive disorder and other mental illness are associated with political conflict. Migrating to foreign countries or working in gulf countries is important stress factors in the family of Nepali people .Many depressed people worried that they are going to be mad which is wrong. 7. In many occasion patients with mania become violent need to take precaution while taking history & examination & management. Hypomania in female is difficult to diagnose appear as depression make poor relation in family. 8. In many occasion patients with anxiety disorder reach to cardiologist thinking that they have heart problems. 9. Patients with conversion disorder show episodic interesting signs & symptoms. They may show attention seeking behavior. For management need to discourage it (cut off secondary gain). Many patients with conversion disorder refuse that they have stress, however we get stress factor on background. In context of Nepal many conversion disorder patients later fulfill the diagnosis of depression. 10. In many occasion patients with somatoform disorder shows symptoms of acid peptic disease (ulcer). They change many doctors not better after taking medicine for ulcer. They do medical shopping behavior. 11. It is very difficult to treat dementia and Mental retardation. In fact only 10℅ are cured & other patients need supportive treatment because of danger for self & other. Treating these patients dose of drugs need to be decreased. 12. In many occasion person with psychosexual disorder don’t go to hospital & they think it is normal behavior and fear to give history. 13. Many children with depression show physical symptoms for long time like headache, pain abdomen, body ache difficulty to make diagnosis need leading question need to add history from patients and teachers. 14. Treating mentally ill person is difficult and challenging. Just giving drugs is no meaning. We should provide good counseling & psychotherapy for complete management. 15. In fact many patients with mental illness go to traditional healer (Dhami, Jhankri’s) thinking that it cures their problem than going to hospital. It is necessary to give basic training about mental illness for traditional healers. 16. Suicidal thinking is dangerous sign of any types of mental illness. We shouldn’t forget to check it with mentally ill patients. If a patient is suicidal, patients should refer to hospital immediately for admission. References 1. WHO International Consortium in Psychiatric Epidemiology. Cross-national comparisons of the prevalences and correlates of mental disorders. Bulletin of the World Health Organization 2000; 78:413-25. 2. World Health Organization. The world health report 2001. Mental health: new understanding, new hope. Geneva: World Health Organization; 2001. Available from. 3. 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