Nepali Times
Disturbed care


Rama (not her real name) was forced to spend seven "hellish" years in the Central Jail for a mental disorder that could have been alleviated if she had received medical help in time. The trauma of trying to conceive for 23 years, and putting up with mockery from society for this "failure" eventually took their toll, and Rama collapsed, emotionally and mentally.

But more than any of that suffering, it is the recollection of life in the Central Jail that sends shivers down her spine now. "Even now, I am terrified when if I think of what I suffered there," says the gentle, soft-spoken woman.

It is common practice in this country to imprison mentally ill people. The general public is told little about neuroses, and the few psychiatric institutions there are little-known. That is why, instead of seeking psychiatric assistance, Rama's family took her to the Central Jail where she was locked up for more than seven years. And she was lucky-the recent fire in a southern Indian asylum, which killed over 20 inmates who were chained to their beds, is a shocking reminder that the trauma of institutionalised people is often not "in the head."

Instead of ensuring the human rights of the ill and their right to treatment, existing laws legitimate such inhuman treatment. Local administration laws grant chief district officers (CDO) the right to put mentally ill people into jail for their own safety or for the safety of the community upon the recommendation of a doctor. But CDOs are not given a concomitant responsibility to protect the rights of disturbed people. And there is no legal provision to reverse this "mentally sick" certification, even if the person's condition improves.

A person's mental health is mainly determined by genetics, environment (like family and work atmosphere), and individual factors like susceptibility to tension or depression. Everyone has their own breaking point, and when this point is reached, a person develops a mental disturbance.

There is no official study on prevalence, but researchers estimate that about 12 percent of Nepalis suffer from some form or degree of mental illness at any given time, and at least two percent suffer from severe but treatable mental illness. Even the presence of four million suffering people has failed to instil a sense of urgency among policymakers and public health officials. Though a National Mental Health Policy was announced in 1997, the issue is still treated as separate from other human development endeavours. Only 0.14 percent of the national health budget was allocated to mental health programmes in fiscal 2000.

The general perception about mental sickness is perhaps reflected in the policies. Here too, the issue remains a taboo subject, and the ailment, one that only affects "the poor, uneducated, underprivileged and downtrodden." But researchers the world over have been saying for some time now that the prevalence rate for mental illness is similar everywhere-in developed and under-developed countries, in cities and in villages. The difference lies on the types of disorders, which often depends on the environment the patients work and
live in.

But there are some factors that pose a greater threat to the mental well-being of people. In countries like Nepal, for example, city dwellers are considered more likely to suffer from the kind of stress that precipitates mental disorders. Changing lifestyles, like the spread of the nuclear family, and pressure to keep up with the neighbours, test the strength of protective cultural mechanisms available to earlier generations-think yoga, meditation, puja-and children and young adults in particular are finding it difficult to cope with the resultant stress and depression.

The Department for Mental Health at the Tribhuvan University Teaching Hospital says that close to 25 of every one hundred patients who seek medical help at the hospital are there with a mental disorder. They usually come seeking treatment for physical ailments, which turn out to be the physical manifestation of mental illnesses. And, they belong to all social and economic classes and caste groups.

But, mental health professionals stress, it is logical that some people are more at risk for certain mental illnesses. "Due to their disadvantaged position, rural women in Nepal are more vulnerable to depression," said Raija Kiljunnen, a clinical psychologist with the Mental Health Programme of the United Mission to Nepal.

Unfortunately, women are again on the losing end when it comes to treatment-very few can actually get medical attention. Patan Mental Hospital shows that while the number of people using mental health services has doubled in the last ten years, male patients outnumber female patients by almost 16 percent. Often, women's families are simply unwilling to seek medical help, and health workers do not realise that the needs of men and women patients are different.

"Medical care and emotional support both play an equally important role in the treatment of mentally disturbed people," said Kedar Subedi, a social worker with Asha Deep, a non-governmental rehabilitation centre for mentally disturbed. But such is the stigma attached to people who suffer from mental disorders, that they receive exactly the opposite. Sometimes even people who have completely recovered are not welcomed back into their homes. Hema, a high school graduate, was not allowed back into her husband's home even though the psychiatrist at Asha Deep assured them that she was perfectly alright. "I was forced to go back to my parents' house and I have been cruelly separated from my young sons," said a tearful Hema.

Where only one person was suffering, now an entire family has been traumatised. Patan Mental Hospital's Dr Dhruba Shrestha says the loss from such behaviour-and the dangerous domino effect it can have, triggering more illnesses or disorders-is incalculable. The 1993 World Development Report estimated that the world loses more productivity due to mental disorders than diseases like tuberculosis, cancer or heart disease. Similarly, the World Health Organisation in 1998 estimated that more working days are lost from mental illness than physical illness. Leave aside the burden on patients' families due to the cost of treatment and care, the social losses due to uncared-for mentally disturbed people like interrupted education, inability to work to their fullest potential, violence, family and marital disharmony are extremely worrying.

A health worker put it like this: "Until we are unafraid of looking mentally ill people in the eye, and until we can guarantee them care, we can forget about checking the social costs of mental illness."

(11 JAN 2013 - 17 JAN 2013)