By Avant Shrestha
According to WHO one out of every four people at one point in their life suffer from mental health issues. Europe and North America are reporting rising diagnosis rates among their population. Similarly, as reported in one of the national dailies, mental health problems in Nepal are increasing with 2% of the country’s total population suffering from mental diseases while 5%of the population suffers from mental problems. As a result, people are facing an issue that hasn’t loomed this large before.
Progressing towards the model of developed nations has no doubt attributed in making living conditions throughout most of the world ideal, as science and surplus has flourished. Although developing countries don’t fear famine or drought as they once did, a greater part of the population in them are diagnosed with issues that weren’t previously in focus. For a start, stroke and heart diseases are claiming more lives than epidemics or wars.
Mental health along with these issues is now growing in relevance. Experts predict that by 2030, depression alone is likely to be the third leading cause of disease in low income countries and the second highest cause of disease burden in middle income countries.
A Brief History of Mental Illness
Mental illnesses have accompanied humans since the dawn of civilisation. 4000 years ago Mesopotamians and Egyptians wrote about hysteria caused by ‘a wandering uterus’ among women. Cave art from as early as 6500 BC has been identified as depicting surgical drilling into the brain to treat epilepsy and let evil spirits escape. The ancient Chinese concept of mental illnesses was attributed to imbalances in the people’s “Yin and Yang” (positive and negative body forces). The history of the mind suffering is a long one, but the history of modern Psychiatry itself, the study and treatment of mental illnesses, has only stretched as far as a few hundred years back.
Private madhouses sprung up in Europe in the middle of the 17th to the 18th century and the first US ward for the insane was established only in 1729. Back then, the stigma for both the mentally ill and those who wished to cure them was much greater than today. Many public movements towards the fairer treatment of the mentally ill such as the “Asylum Movement” and the “Non-Restraint Movement” were required to make strides towards creating a greater understanding of mental illness. Over time, (and this is a huge oversimplification of history) the view of the mentally deranged as well as how to treat them, was on the track towards change in Europe and the Americas through the acts of prominent individuals in the field such as Emil Kraeplin (1856-1926), Eugen Bleuler (1857-1939), Sigmund Freud (1856-1939) and many others.
Mental Health and Nepal
Nepal was no different when it came to topic of mental health; usually nonchalantly ignoring the idea of mental health and issues altogether. The labels and the stigmas associated to a mentally ill individual was attributed to his or her past sins, superstitions or to the will of gods rather than understanding the medical probabilities of the illness. These aspects are still evident in Nepal. As a result, many people in Nepal tend to hide their mental health issues for the fear of stigmatisation and possible isolation from the society. Many in rural areas were and still are taken to witch-doctors, chained or abandoned in sheds. These aspects all seem primitive but superstitions and social constraints surrounding mental health are still prevalent in many communities in the nation.
Stating these facts Nepal in recent times has had progressive and sensitised outlook towards mental illness. Both governmental and non-governmental organisations have run programs, clinics and awareness campaigns in regard to mental health and the issues they are aiming to tackle. However, efforts are mainly concentrated to the urban areas.
Mentally ill patients and events surrounding mental health is sensationalized. The images of keeping the patients in an asylum, in isolation and shock therapy is 100% wrong and misguided.
Dr. Anurag Misra
Consultant, Department of Neuro-Psychiatry, Grande Hospital
In low and middle income countries like Nepal, 76% and 85% people with mental disorders receive no treatment.
Dr. Pawan Sharma
Consultant Psychiatrist, Arogin Health Care
Understanding Mental Health and Physical Health
Mental wellbeing is defined as a state in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. The definition and the effects of mental illnesses are far more ranging than any layman would suppose. Mental illness can be divided into two categories; psychotic and neurotic. Illness such as anxiety, depression and sleeping disorder can be categorised as neurotic mental illness and conditions such as bipolar disorder and schizophrenia fall under the psychotic mental illness.
Additionally, mental health of an individual is directly related to the physical well-being of an individual as well. There are multiple associations between mental health and chronic physical conditions that significantly impact an individual’s quality of life. Dr Anurag Misra, Consultant at Department of Neuro-Psychiatry at Grande Hospital explains, “We have to understand that the parts of the body have a wholly symbiotic relationship. Severe mental illnesses and waning physical conditions are directly proportional. For example, people with higher levels of self-rated distress are 32% more likely to have died from cancer”. What Dr. Misra has attempted to outline in his statement is that if a person with a stable mental health condition is diagnosed with cancer, he or she is more likely to battle the disease and make an effort to get better, however if an individual with weak mental health is diagnosed with cancer, he or she will be more likely to give up and succumb to the disease.
A 2017 article published by Princeton University emphasised that untreated mental illness can lead to the conditions worsening over time. Physical health issues such as chronic pain, financial problems, lack of job stability, being taken advantage of by others, and death by suicide. In fact, 90% of suicides are caused by mental illness. Doctors and medical professionals have outlined some of the reasons mental illnesses can exacerbate and worsen physical health issues. Primarily because mentally ill people are statistically less likely to receive the physical healthcare they’re entitled to such as routine blood pressure, cholesterol and weight checks. Additionally, mentally ill people are also much less likely to be offered the help to give up smoking, alcohol and make positive adjustments to their diet.
Dr Misra adds, “Schizophrenia is associated with doubling the risk of death from heart diseases, and depression has been found to be associated with an increased risk of coronary heart diseases.”
Here and Now
According to Dr. Sharma, in low and middle income countries like Nepal, 76% and 85% people with mental disorders receive no treatment. This lack of treatment for such a large proportion of people is no doubt a result of the woefully small number of psychiatrists and psychologists in the nation. In Nepal, mental health and illness is one of the least prioritized areas of development. A significantly large section of the population is still deprived of the basic health service. Additionally, in health sectors, mental health services lack the required professionals to supervise mental issues or are not fully integrated and local health professionals still lack an understanding of mental health and psychosocial wellbeing.
Dr. Pawan Sharma, Consultant Psychiatrist at Arogin Health Care describes many cases where he has felt the dearth of manpower in the nation. “I have to see around 40-50 patients a day, unlike in other countries we cannot give 30 or so minutes to every individual,” he states. Dr. Sharma is one of the few mental health practitioners in the country; and the insufficient number of trained professionals means that shamans and witch-doctors are generally the leading authority in the rural areas as far as this illness is concerned.
A study conducted by HERD (Health Research and Social Development Forum) in 2016 claims that there are only 0.22 psychiatrists and 0.06 psychologists per 100,000 populations. The lack of manpower is also clearly seen in the treatments prescribed by doctors in Nepal, favoring the use of medication rather than psychotherapy and long sessions due to time constraints. This increasing reliance of medication, though effective as treatment, has not helped the image people have of the mentally ill in the nation.
Mental Health problems are highly stigmatised in the community. NGOs have been attempting to raise awareness but are only able to target specific populations with limited funding. Plus, government spending accounts for less than 1% of its total healthcare budget on mental health. This lack of government funded awareness programs is thoroughly felt, once removed from urban settings. Infrastructure in said areas is also poor and special mental health care services have been limited only to zonal and district hospitals.
This lack of manpower, financial resources, awareness and general infrastructure paints a dreary picture of mental health in the country, but slow progress is being made. For example, although still a small number, the number of psychiatrists has greatly increased from past accounts, the number of mental health beds has increased from 1 to 1.5 per 100000, and the advancement of media has resulted in increased awareness by the public.
Misconceptions Loom Large
Dr. Pawan claims, “The general populace has a varied response to mental health issues; ignorance on the subject persists even among educated people.” Myths like mental illnesses are not curable looms large. Mental illness is not taken seriously unless it is debilitating and life threatening. “I hear lots of patients’ family members saying ‘do not be depressed’, ‘snap out your depression’, ‘do not be anxious’, ‘do not have negative thoughts,” says Dr. Pawan. “Even other professionals in the medical field feel a sense of amusement while referring a patient to psychiatrists. And there is a general lack of preference given to the field within the discipline itself,” he adds.
One of the major contributions in regard to the misconception of mental health and illness is our culture itself. The beliefs and misconceptions that have been passed on for generations has proved to be difficult to change. Additionally, the portrait of mental illness in the popular media such as movies and television has contributed to the negative perception of the illness. Dr. Misra claims, “Mentally ill patients and events surrounding mental health is sensationalised. The images of keeping the patients in an asylum, in isolation and shock therapy is 100% wrong and misguided.”
Similar to the claims made by Dr. Misra, Dr. Sharma, explains, “The media with a lack of awareness is responsible for this negative outlook on the subject matter. Over sensationalising and borderline glorifying representation of suicide and mental illnesses in movies and television shows, and further social media and internet culture are the perpetuator of suspicion towards mental health practices and the effectiveness of medication.”
Additionally, Dr. Misra claims that one of the biggest problems in Nepal is lack of awareness. “There is no proper information. The patient is usually timid and tends to keep his or her condition hidden in the fear of being stigmatised and castrated from the society. They are very conscious of what other people might think of them, which I believe is very harmful,” Dr. Misra illustrates.
Alok (name changed on request), a 29-year-old architect, is one of the many suffering from anxiety and ADHD for most of his adult life. He claims that it is difficult to openly talk about his condition in Nepal. Alok claims, “Personally and professionally I suffer due to my condition. I believe if I am open about my condition, it will be easy for people to pass judgments and it will only hurt my professional life.” Like Alok, there are a number of individuals who have to silently suffer through their condition.
According to Dr. Misra, to change public perception, we have to start from the government level and increase awareness. For example, depression needs to be understood as a critical illness and with the help of therapy and medication this can be reduced or at least kept under control. “What people and patients should be aware of is that this is just a disease, with proper medical diagnosis and medication, there are high chances that the problem will subside,” Misra shares.
Dr. Sharma states, “Mental illness is not caused by personal weakness and is not ‘cured’ by personal strength. Seeking and accepting help is a sign of strength. A mental illness is not a character flaw. It is caused by interaction of genetic, biological, social and environmental factors. With appropriate treatment and support, people with mental illness can have a normal life and live successfully in their community.”
As with every field of science, new discoveries in mental health manage to change the way we view the subject. New methods of treatment are pioneered and backed up by years of work from individuals who are the best in the field.
Alok explains, “When it comes to mental health and illness, I think our country lags behind both in terms of culture and education. Accurate awareness is the key element in Nepal; just because I along with many other suffers from some conditions doesn’t mean that we are psychotic. We are just normal people with normal lives who just happen to need help from time to time and the fact that we are judged when we actually need help leaves us totally isolated.”
However, there are positive signs to claim that the understanding and acceptance of mental health and illness are changing. Dr. Misra states, “In the past the number of doctors who worked with mental health issues was dismal but now more people are educated in this department and more doctors are certified and trained.”