Mental health care in Nepal: current situation and challenges for development of a district mental health care plan

Nagendra P Luitel, Mark Jd Jordans, Anup Adhikari, Nawaraj Upadhaya, Charlotte Hanlon, Crick Lund, Ivan H Komproe, Nagendra P Luitel, Mark Jd Jordans, Anup Adhikari, Nawaraj Upadhaya, Charlotte Hanlon, Crick Lund, Ivan H Komproe

Abstract

Background: Globally mental health problems are a serious public health concern. Currently four out of five people with severe mental illness in Low and Middle Income Countries (LMIC) receive no effective treatment. There is an urgent need to address this enormous treatment gap. Changing the focus of specialist mental health workers (psychiatrists and psychologists) from only service delivery to also designing and managing mental health services; building clinical capacity of the primary health care (PHC) workers, and providing supervision and quality assurance of mental health services may help in scaling up mental health services in LMICs. Little is known however, about the mental health policy and services context for these strategies in fragile-state settings, such as Nepal.

Method: A standard situation analysis tool was developed by the PRogramme for Improving Mental health carE (PRIME) consortium to systematically analyze and describe the current gaps in mental health care in Nepal, in order to inform the development of a district level mental health care plan (MHCP). It comprised six sections; general information (e.g. population, socio-economic conditions); mental health policies and plans; mental health treatment coverage; district health services; and community services. Data was obtained from secondary sources, including scientific publications, reports, project documents and hospital records.

Results: Mental health policy exists in Nepal, having been adopted in 1997, but implementation of the policy framework has yet to begin. In common with other LMICs, the budget allocated for mental health is minimal. Mental health services are concentrated in the big cities, with 0.22 psychiatrists and 0.06 psychologists per 100,000 population. The key challenges experienced in developing a district level MHCP included, overburdened health workers, lack of psychotropic medicines in the PHC, lack of mental health supervision in the existing system, and lack of a coordinating body in the Ministry of Health and Population (MoHP). Strategies to overcome these challenges included involvement of MoHP in the process, especially by providing psychotropic medicines and appointing a senior level officer to facilitate project activities, and collaboration with National Health Training Centers (NHTC) in training programs.

Conclusions: This study describes many challenges facing mental health care in Nepal. Most of these challenges are not new, yet this study contributes to our understanding of these difficulties by outlining the national and district level factors that have a direct influence on the development of a district level mental health care plan.

Keywords: Integration of mental health into PHC; Mental health; Mental health care plan; Nepal; Situation analysis.

References

    1. Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet. 2013;382(9904):1575–86. doi: 10.1016/S0140-6736(13)61611-6.
    1. Kohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. Bull World Health Organ. 2004;82(11):858–66.
    1. WHO . Mental Health Gap Action Programme (mhGAP): Scaling up care for mental, neurological and substance use disorders. Geneva: World Health Organization; 2008.
    1. Lund C, Breen A, Flisher AJ, Kakuma R, Corrigall J, Joska JA, et al. Poverty and common mental disorders in low and middle income countries: A systematic review. Soc Sci Med. 2010;71(3):517–28. doi: 10.1016/j.socscimed.2010.04.027.
    1. Teferra S, Shibre T, Fekadu A, Medhin G, Wakwoya A, Alem A, et al. Five-year mortality in a cohort of people with schizophrenia in Ethiopia. BMC Psychiatry. 2011;11:165. doi: 10.1186/1471-244X-11-165.
    1. Kakuma R, Minas H, van Ginneken N, Dal Poz MR, Desiraju K, Morris JE, et al. Human resources for mental health care: current situation and strategies for action. Lancet. 2011;378(9803):1654–63. doi: 10.1016/S0140-6736(11)61093-3.
    1. WHO . Mental Health Atlas 2011. Geneva: World Health Organization; 2011.
    1. Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, et al. Scale up of services for mental health in low-income and middle-income countries. Lancet. 2011;378(9802):1592–603. doi: 10.1016/S0140-6736(11)60891-X.
    1. Patel V, Weiss HA, Chowdhary N, Naik S, Pednekar S, Chatterjee S, et al. Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Lancet. 2010;376(9758):2086–95. doi: 10.1016/S0140-6736(10)61508-5.
    1. van Ginneken N, Tharyan P, Lewin S, Rao GN, Meera SM, Pian J, et al. Non-specialist health worker interventions for the care of mental, neurological and substance-abuse disorders in low- and middle-income countries. Cochrane Database Syst Rev. 2013;11:Cd009149.
    1. Cohen A. The Effectiveness of Mental Health Services in Primary Care: The View from the Developing World. Geneva: WHO; 2001.
    1. Patel V. The future of psychiatry in low- and middle-income countries. Psychol Med. 2009;39(11):1759–62. doi: 10.1017/S0033291709005224.
    1. Singh S, Dahal K, Mills E. Nepal‟s war on human rights: a summit higher than Everest. Int J Equity Health 2005, 4(9) doi:10.1186/1475-9276-4-9
    1. Singh S. Impact of long-term political conflict on population health in Nepal. Can Med Assoc J. 2004;171(12):1499–502. doi: 10.1503/cmaj.1040777.
    1. MoHP . National Mental Health Policy. Kathmandu: Ministry of Health and Population; 1997.
    1. MoH . National Health Policy 1991. Kathmandu: Ministry of Health; 1991.
    1. Lund C, Tomlinson M, De Silva M, Fekadu A, Shidhaye R, Jordans M, et al. PRIME: a programme to reduce the treatment Gap for mental disorders in five low- and middle-income countries. PLoS Med. 2012;9(12):e1001359. doi: 10.1371/journal.pmed.1001359.
    1. Hanlon C, Luitel NP, Kathree T, Murhar V, Shrivasta S, Medhin G, et al. Challenges and opportunities for implementing integrated mental health care: a district level situation analysis from five low- and middle-income countries. PLoS One. 2014;9(2):e88437. doi: 10.1371/journal.pone.0088437.
    1. WHO . The World Health Report – Mental Health: New Understanding, New Hope. Geneva: World Health Organization; 2001.
    1. WHO . Integrating Mental Health into Primary Care : A Global Perspective. Geneva: WHO; 2008.
    1. UNDP . Human Development Report 2013, The Rise of the South: Human Progress in a Diverse World. New York: United Nation Development Program; 2013.
    1. Thornicroft G, Alem A, Antunes Dos Santos R, Barley E, Drake RE, Gregorio G, et al. WPA guidance on steps, obstacles and mistakes to avoid in the implementation of community mental health care. World Psychiatry. 2010;9(2):67–77.
    1. WHO . mhGAP Intervention Guide for Mental, Nuerological, and Substance Abuse Disorders in non-Specialized Health Settings. Geneva: World Health Organization; 2010.
    1. MoHP ERAN, Inc II . Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland; 2012.
    1. WHO . WHO-AIMS Report on Mental Health System in Nepal. Kathmandu: World Health Organization and Ministry of Health; 2006.
    1. Regmi S, Pokharel A, Ojha S, Pradhan S, Chapagain G. Nepal mental health country profile. Int Rev Psychiatry (Abingdon, England) 2004;16(1–2):142–9. doi: 10.1080/09540260310001635186.
    1. Pradhan S, Sharma S, Malla D, Sharma R. A study of help seeking behavior of psychiatrist patients. J Kathmandu Med Coll. 2013;2(3):21–4.
    1. Shrestha M, Pradhan S, Sharma S. Morbidity pattern of psychiatric disorders in patient seeking treatment in psychiatric OPD of private tertiary care hospital. Postgrad Med J NAMS. 2011;11(1):28–33.
    1. MWCSW . National Minimum Standard for the Care and Protection of Victims/Survivors of Trafficking in Persons. Ministry of Women, Children and Social Welfare: Kathmandu; 2012.
    1. Luitel NP, Jordans MJ, Sapkota RP, Tol WA, Kohrt BA, Thapa SB, et al. Conflict and mental health: a cross-sectional epidemiological study in Nepal. Soc Psychiatry Psychiatr Epidemiol. 2013;48(2):183–93. doi: 10.1007/s00127-012-0539-0.
    1. Kohrt BA, Speckman RA, Kunz RD, Baldwin JL, Upadhaya N, Acharya NR, et al. Culture in psychiatric epidemiology: using ethnography and multiple mediator models to assess the relationship of caste with depression and anxiety in Nepal. Ann Hum Biol. 2009;36(3):261–80. doi: 10.1080/03014460902839194.
    1. Kohrt BA, Jordans MJ, Tol WA, Speckman RA, Maharjan SM, Worthman CM, et al. Comparison of mental health between former child soldiers and children never conscripted by armed groups in Nepal. JAMA. 2008;300(6):691–702. doi: 10.1001/jama.300.6.691.
    1. Tol WA, Komproe IH, Thapa SB, Jordans MJ, Sharma B, De Jong JT. Disability associated with psychiatric symptoms among torture survivors in rural Nepal. J Nerv Ment Dis. 2007;195(6):463–9. doi: 10.1097/NMD.0b013e31802f5dac.
    1. Thapa SB, Hauff E. Psychological distress among displaced persons during an armed conflict in Nepal. Soc Psychiatry Psychiatr Epidemiol. 2005;40(8):672–9. doi: 10.1007/s00127-005-0943-9.
    1. MoHP . Maternal Mortality and Morbidity Study, 2008/09. Kathmandu: Ministry of Health and Population; 2009.
    1. Upadhyaya K, Nakarmi B, Prajapati B, Timilsina M. Morbidity profile of patients attending the centers for mental health service provided jointly by the Government of Nepal and Community mental health service of Community Mental Health and Counseling- Nepal (CMC-Nepal) J Psychiatrists’ Assoc Nepal. 2013;2(1):14–9.
    1. Raja S, Underhill C, Shrestha P, Sunder U, Mannarath S, Wood SK, et al. Integrating mental health and development: a case study of the BasicNeeds Model in Nepal. PLoS Med. 2012;9(7):e1001261. doi: 10.1371/journal.pmed.1001261.
    1. MoHP . Mainstreaming psychosocial care in the existing health care system for children affected by AIDS. Kathmandu: Ministry of Health and Population; 2012.
    1. Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, et al. Barriers to improvement of mental health services in low-income and middle-income countries. Lancet. 2007;370(9593):1164–74. doi: 10.1016/S0140-6736(07)61263-X.
    1. Jordans MJ, Luitel NP, Tomlinson M, Komproe IH. Setting priorities for mental health care in Nepal: a formative study. BMC Psychiatry. 2013;13:332. doi: 10.1186/1471-244X-13-332.
    1. Jordans, M.J.D., Kohrt, B.A., Luitel, N.P., Komproe, I. & Lund, C. (In press). Accuracy of pro-active case finding for mental disorders by community informants in Nepal. British Journal of Psychiatry.
    1. MoHP . Nepal health sector support programme implementation Plan II (2010–2015) Kathmandu: Ministry of Health and Population; 2010.
    1. MoHP . Hospital Based One-stop Crisis Management Centre (OCMC) Operational Manual, 2067 (official Nepali version) Kathmandu: Ministry of Health and Population; 2011.
    1. Jordans MJ, Upadhaya N, Tol W, Shrestha P, Doucet J, Gurung R, et al. Introducing the IASC Mental Health and Psychosocial Support Guidelines in Emergencies in Nepal: a process description. Intervention. 2010;8(1):52–63. doi: 10.1097/WTF.0b013e3283346497.
    1. Ventevogel P, van de Put W, Faiz H, van Mierlo B, Siddiqi M, Komproe IH. Improving access to mental health care and psychosocial support within a fragile context: a case study from Afghanistan. PLoS Med. 2012;9(5):e1001225. doi: 10.1371/journal.pmed.1001225.
    1. WHO . Building Back Better: Sustainable Mental Health Care After Disaster. Geneva: World Health Organization; 2013.
    1. Ovuga E, Boardman J, Wasserman D. Integrating mental health into primary health care: local initiatives from Uganda. World Psychiatry. 2007;6(1):60–1.
    1. Kohrt BA, Blasingame E, Compton MT, Dakana SF, Dossen B, Lang F SP, J C (In Press): Adapting the Crisis Intervention Team (CIT) Model of Police–Mental Health Collaboration in a Low-Income, Post-Conflict Country: Curriculum Development in Liberia, West Africa. American Journal of Public Health
    1. Harwin J, Barron T. The Role of Service Delivery Non Governmental Organisations in Policy Reform. Child Abuse Rev. 2007;16:367–82. doi: 10.1002/car.1008.
    1. Thara R, Patel V. Role of non- governmental organizations in mental health in India. Indian J Psychiatry. 2010;52:389–95. doi: 10.4103/0019-5545.69276.
    1. Pérez-Sales P, Férnandez-Liria A, Baingana F, Ventevogel P. Integrating mental health into existing systems of care during and after complex humanitarian emergencies: rethinking the experience. Intervention. 2011;9(3):345–57.
    1. Upadhaya N, Luitel N, Koirala S, Adhikari R, Gurung D, Shrestha P, et al. The role of mental health and psychosocial support NGOs: Reflections from post-conflict. Nepal Intervention. 2014;12(Supplement 1):113–28. doi: 10.1097/WTF.0000000000000064.
    1. Somasundaram D, van de Put W, Eisenbruch M, de Jong J. Starting mental health services in Cambodia. Soc Sci Med. 1999;48(8):1029–46. doi: 10.1016/S0277-9536(98)00415-8.
    1. Silove D, Steel Z. Understanding community psychosocial needs after disasters: implications for mental health services. J Postgrad Med. 2006;52(2):121–5.
    1. Kohrt BA, Hruschka DJ, Worthman CM, Kunz RD, Baldwin JL, Upadhaya N, et al. Political violence and mental health in Nepal: prospective study. Br J Psychiatry J Ment Sci. 2012;201(4):268–75. doi: 10.1192/bjp.bp.111.096222.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren