Nepali Times

Shanti arrives at a clinic in rural Nepal complaining of aches and pains. The clinician examines and sends her to the lab for some tests, all of which are normal. In the last few years, she has spent a lot of time and money seeing generalists who tell her there is nothing wrong.

The clinician suggests this could be psychological; she should see a psychiatrist. Shanti is offended that the generalist thinks she is “crazy”. Besides, the nearest psychiatrist is more than a day’s trip away.

In a recently published study, our team at Possible spoke with 29 MBBS physicians, Health Assistants and Certified Medical Assistants from three district hospitals. Generalists described two groups of patients with mental illness.

For the first group, the patients’ sense of reality is altered, resulting in severe behavioural problems in patients like Shanti. Generalists quickly recognised the need for a psychiatrist, and noted that well-resourced families take such patients to the nearest psychiatrist while poorer patients visit traditional healers. Patients who do not improve may be isolated and locked away for the rest of their lives.

Patients in the second group, however, continue to see health workers in private or government hospitals. In primary care clinics, almost 20 per cent of the patients have aches, pains, dizziness, and numerous other problems that have no clear source. Generalists usually suspect an underlying mental illness, but do not know what to do next. In desperation, they prescribe vitamins and painkillers, but the patients do not improve. Aches and pains move to a different part of the body, or the patient seeks services at another facility, spending more money on visits and repeated lab tests.

Often, patients hear stigmatising and dismissive comments about their problems from generalists: women are told their anxious response to domestic violence is a sign of weakness, others are told there is “nothing wrong” with them. These words are meant to normalise the situation and somehow comfort the patient, but have the consequence of patients thinking that they are being blamed or that their suffering is being dismissed as a non-issue.

Even though the generalists know that such patients require more time, they report being too busy to sit down with the patients to learn more about what ails them. With more than 70 patients waiting to be seen, it is easier to say a few words of reassurance and prescribe vitamins.

In Nepal, medical schools and other health professional institutes include minimal to no mental health training. This is incredibly inadequate because mental illnesses are the biggest cause of chronic diseases. Such neglect has left our healthcare workforce woefully unprepared to care for people with depression, anxiety disorders, dementia, psychosis, epilepsy and substance abuse. This ‘educational gap’ among generalists is particularly concerning in the context of humanitarian crises like the earthquakes in 2015.

In response to these findings, our team has implemented a program to provide high-quality mental health care integrated into the primary care clinic at Bayalpata Hospital in Achham district. The strategy prevents patients from the costly and often stigmatising process of visiting a psychiatrist in the city. We have trained all generalists to recognise mental illness and avoid harmful and ineffective medications. We have recruited counsellors trained by Transcultural Psychosocial Organization (TPO-Nepal). When a generalist suspects mental illness, the counsellors conduct a thorough evaluation and make treatment recommendations. Sikhar B Swar, a Kathmandu-based psychiatrist, reviews cases and travels to Achham for training and supervision.

There are many all around Nepal who are receiving inappropriate or no mental healthcare. To address this, medical institutes must train our healthcare workforce in mental health. Generalists should be comfortable recognising and treating mental illness like any other common illness. In addition, psychiatrists must engage in training and supervising generalists and counsellors.

Given the severe shortage of psychiatrists, particularly in rural Nepal, patients cannot all be directly seen by a psychiatrist. The government must include counsellors as part of the workforce around the country. The cost of training and supporting counsellors is a very small price to pay for the benefit of avoiding unnecessary tests and clinic visits, setting aside time for the busy generalists, and providing non-stigmatising mental health services.

The post-earthquake period has increased the nation’s attention to mental health. Now we have a clear choice: do we roll out services that are affordable and effective, or do we keep telling patients suffering from a real illness that there is nothing wrong with them?

Bibhav Acharya, MD is the Co-Founder and Mental Health Adviser for Possible, which operates a healthcare delivery system in Achham and Dolakha in partnership with the Nepal Government. Soniya Hirachan, MD is the Co-Founder of Shared Minds, a non-profit that provides mental health training for generalist clinicians in Nepal.

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