History of mental health in Nepal is not long and started from Bir hospital.Now many medical college providing good services.Chitwan medical college provide an excellent services for mentally ill people,l

 

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.