Badri Chapagain, the district health officer of Jumla, received a phone call as we finished dinner in his quarters last month. The hospital was summoning him to confirm the cause of death of a suspected suicide.
Next day, reports on Radio Karnali and bajar talk revealed that an ex-Maoist, Sagar, had hanged himself in the room where his wife was sleeping. Sagar's suicide echoed the distress of the many mental patients we saw at a three-day health camp in Jumla organised by the district health office and World Vision at the request of CPN-M leaders to coincide with their Karnali exhibition. With the flag of the Maoist Republican People's Health Movement fluttering above us, we examined cadres and locals suffering from anxiety, depression, post-traumatic stress disorder (PTSD), and other psychiatric problems.
As in the rest of the country, Jumla lacks a basic mental health infrastructure. The approximately 30 psychiatrists in Nepal are all in major cities. Few health post workers have training in mental illness. Psychiatric medications are rare outside urban centres. Most psychiatric patients in the Jumla health camp will need to get their medications from Nepalganj.
The tremendous burden of mental illness in rural Nepal makes the lack of services more worrying. Even before the conflict, rates of mental illness were high. In 2000, 38 percent of women and 24 percent of men in Jumla suffered from depression. Conflict has only exacerbated the mental health crises. Eighty percent of internally displaced people in the midwest suffer from depression, while 55 percent have PTSD. Recent research by Transcultural Psychosocial Organisation Nepal has found that 60 percent of child soldiers have high levels of PTSD symptoms, while 33 percent of children never associated with armed groups have elevated symptoms.
There is hope for addressing both conflict related and other mental health problems. The first step is raising awareness. Non- governmental psychosocial experts are training local staff in mental health issues but there is a worrying gap in awareness among professionals and Kathmandu-based staff. The stigma travels up to the level of donors; a colleague recently advised me not use the term 'mental health' in a proposal or the project would not be funded. A hospital administrator told a colleague, "It is worse to be a crazy doctor (a psychiatrist) than a crazy patient."
Chapagain in Jumla is an exception. The doctor says his most rewarding clinical experience is to see very depressed patients return to his clinic smiling, laughing, and interacting with their family after starting treatment. Health post staff need mental health knowledge as well. The previous Institute of Medicine and United Mission to Nepal Community Mental Health Program served this purpose, but the government now needs to increase funding for the training of community health workers.
Psychosocial counsellors are also needed. Jumla is fortunate to have two of them who, a recent study shows, reduced children's depression by 21 percent and PTSD by 31 percent. Sadly, with money running out, their counselling program is in jeopardy. Quality control is also crucial. Some NGO staff refer to themselves as psychosocial counsellors after only a weeklong orientation. Government and professional organisations should develop a certification system for the range of personnel acting in the mental health field.
The health camp in Jumla represents a step toward collaborative and beneficial care. Continued local activities are necessary. In addition, the donor and NGO community need to view mental health as a human right for which all persons should have access to services. We should be able to tell the families of Sagar and other women, men, and children with psychological distress that in the new Nepal suicide prevention, and other mental health services are priorities.
Brandon Kohrt is an MD-PhD candidate at Emory University and a research technical advisor to Transcultural Psychosocial Organisation Nepal (www.tponepal.org).
