LAGANKHEL, NEPAL – It is midafternoon, and the outpatient department at Nepal’s only mental health facility, called the Mental Hospital, is abuzz with patients. Some wait for their turn to receive care, while others sit on the hospital lawn, crying, talking to themselves or just soaking in the sun.
Saraswoti Poudel, 25, says she was admitted five days ago to the hospital in Lagankhel, located in the Lalitpur district in central Nepal. She says she started struggling with depression after getting married five years ago.
“I’m here to seek medication,” she says as she walks back and forth on the hospital lawn.
Poudel, who hails from Rautahat, a district south of Lalitpur, is wearing a red sweater, long tunic and trousers. The vermillion powder, a traditional indication of married Nepali women, is dripping from her hair to her forehead. Poudel says she isn’t fond of maintaining her personal hygiene. Her eyes look drowsy from her medication.
“Life is worthless,” she repeats.
She says she was enrolled in college until her parents forced her to withdraw and marry her husband, Rupesh Poudel, from Sarlahi, the district to the east. She says she didn’t want to get married and that it was difficult to start fresh in a new household and community. She says her new family looked down on her for not excelling at domestic skills.
“The ways my in-laws treated me was disheartening,” Poudel says. “I tried to console myself but couldn’t.”
Her husband says that Poudel was social and fun-loving before they got married, but soon afterward she drowned herself in her thoughts and started becoming sarcastic, an unusual trait among Nepali women. He says she became irritated for no reason, looked depressed and refused to have sexual intercourse with him.
Her husband says he became increasingly worried and took her to a clinic, where she received a blood test, X-ray, ultrasound and even a CT scan. With suggestions from neighbors, he even tried local faith healers. But he says nothing worked. When Poudel started becoming verbally and physically aggressive, he says he admitted her to the mental hospital.
“After she was admitted and given two doses of medicine, she seemed normal,” he says. “She talks well.”
But she says her problems will just worsen once she returns home.
“When I’ll return to my village, people are going to call me a mad woman,” she says. “How am I supposed to live?”
An increasing number of women in rural areas report suffering from mental illness. Experts attribute this to poverty, illiteracy, gender injustice, civil war and neglect. Doctors cite a lack of facilities, knowledgeable personnel and government support in treating these women. Government officials say policies are in place, but they just need to be executed.
In Nepal, there has been a gradual increase in awareness of mental health in the general population and the number of people seeking treatment, according to a 2006 World Health Organization, WHO, report. There is a national mental health policy, and psychotropic drugs are now widely available.
But Nepal has only one official psychiatric hospital, and mental health services are scarce in remote and rural areas, according to the WHO. Recent statistics on mental illness and effective health legislation are also lacking. Financial constraints complicate care, as the majority of Nepalis live in extreme poverty. To date, the government has allocated little of the budget to mental health care.
About six miles from Kathmandu, the capital, there is another facility for psychiatric patients. Established in 1994, Ashadeep Residential, Treatment and Rehabilitation Center currently has 36 patients, 16 of whom are women.
Suntali Gurung, a patient from Sindhupalchowk, a district to the northeast of Kathmandu, has made the center her home for nine years.
Gurung says that her parents died when she was young, and she was brought to Kathmandu to work in a carpet factory. She was living comfortably until the factory closed. She says her friends advised her to marry so she could have some financial security. She married Prem Bahadur Gurung, a policeman, when she was 30.
Gurung says she was elated to be in a relationship and be attached to someone she could call her own. After five years of marriage, she had a son and a daughter.
But then suddenly she overheard rumors that her husband was having an affair with another woman from the neighborhood. Gurung says she barged into the police station where her husband worked to confront him. After that day, he visited the house only occasionally, which Gurung says strained her.
“Someone who I thought was a part of me betrayed me,” she says. “I couldn’t control myself, which has turned into how I am living today.”
Geeta Sharma, 37, from Panchthar, a district on Nepal’s eastern border, also suffers from a mental health condition. She says when the Maoists, or Communist Party of Nepal-Maoist, overthrew the monarchy in 1996 and started the decade-long civil war, she began to change.
She says many of her neighbors died during the insurgency, and her husband, a teacher then, was abducted by the Maoists and physically and mentally tortured. She says their home was often frequented by Maoists and Nepalese Army personnel, who each accused her and her husband of being spies for the other. Sharma says that financial pressure mounted after the Maoists abducted her husband, and it became difficult to raise their two children.
“A chain of problems pushed me into misery,” she says.
Sharma says that life slowly became meaningless. She says suicidal thoughts sprouted in her mind, and at times she was transported into a senseless state. Eventually some of her fellow villagers took her to India for a medical screening, where Sharma was diagnosed with mental illness.
She has been on medication for nine years. She now lives at home but regularly visits a mental health center for supplies and counseling.
“If I miss my medication for a single day, it seems I am transported back to the past,” she says. “I hear bombs exploding, and when someone comes to the house, it just feels they’re here to take my husband away.”
The stories of Sharma, Gurung and Poudel are mere examples of the state of women living with mental illness in Nepal.
Mental health experts say that these women suffer from “general neurosis mental condition” caused by stress and sadness, a state in which the patients know what they’re going through. People suffering from higher levels of mental illness don’t realize their condition and often tend to sleep on the streets and go without sufficient clothing and food for days.
Dr. Rabi Shakya, a consultant psychiatrist at the Lagankhel mental hospital, says that Sharma, Gurung and Poudel are patients who need to be admitted into the facility.
Shakya says that the number of mental patients is rapidly increasing in Nepal, based on informal studies. Recent national statistics are lacking, but the hospital’s statistics by the end of March showed that there were 100 patients visiting the outpatient department, half of which were women. In Tribhuvan University Teaching Hospital in Kathmandu, statistics show that out of about 20 to 30 patients admitted into its mental illness ward, most of them are women.
Shakya says the main reasons for the higher percentage of women are a lack of awareness about mental health and ignorance by family members.
“It’s only when the symptoms become severe, people come to us,” he says, adding that most patients who visit the hospital have been suffering from mental illness for a long time. “Most of the patients who come here are too difficult to handle because of the severity of the illness.”
Rajesj Jha, a counselor for the Center for Mental Health and Counseling-Nepal, CMC-Nepal, a nongovernmental organization that works on preventative and curative aspects of mental health, says that about 80 percent of families in Humla, Jumla, Salyan and Rolpa, rural districts in Nepal’s Midwestern Region, have women with mental illnesses.
Experts working in this field say that poverty, illiteracy, gender biasness, domestic violence, migration of men and the decade-long Maoist insurgency have contributed to the rising number of women in rural areas suffering from psychiatric problems.
“Mental health of women in rural Nepal isn’t positive,” Jha says. “They need more counseling and also treatment.”
CMC-Nepal provides mental health counseling in these districts. Organizations like Ashadeep have also offered assistance.
But many times family members tend to ignore their responsibilities, which tends to aggravate the patient’s condition, says Suire Baram, an Ashadeep employee.
Gurung’s case resonates with other women Ashadeep has tried to assist. After counseling, her husband took her home. But she says he had remarried and Gurung’s in-laws accused her of being promiscuous, leading her to return to Ashadeep.
Her health is gradually improving, and she is also taking care of other patients in the center. But Gurung says that she misses her children.
“My eyes are glued to the gate with a hope that my children will come to see me someday,” she says. “I’ve already been insane due to my worries before.”
Most of the women with mental illness tend to be bound by their love for their children, says Tara Chaulagain, who has been a mason at Ashadeep for 10 years.
“Even while suffering their mental conditions, I see them breastfeeding their babies,” Chaulagain says. “Women are always bound by their responsibilities even when they lose their sanity. And this is a big difference between male and female patients.”
Ram Lal Shrestha, director of CMC-Nepal, says the government hasn’t focused on producing more doctors, nurses, psychologists, social workers and counselors despite the increase in mental illness.
“The increase in the number of people with psychological [issues] isn’t just a social problem,” he says. “It will affect the country in the long run.”
He says that the government’s budget toward mental health is only 0.8 percent of the total health care budget.
Shakya says that the government’s disregard for mental health in its policymaking makes patients suffer more.
“It’s because the government hasn’t understood the graves of the issue that they haven’t been able to prioritize,” Shakya says.
Additional setbacks include insufficient awareness and knowledge among the health practitioners, he says.
“When they themselves don’t understand the problem, how are they going to solve it?” Shakya asks.
As of now, Nepal has only one mental hospital and 18 hospitals that treat mental illness. The number of medical practioners at these facilities stands at 51 psychiatric doctors, 11 psychologists and 48 nurses. The ratio of patients to beds is 71,177-1, says Shakya, pointing at a chart in his office. Most care is done through outpatient facilities, according to the WHO report.
The Nepal Health Sector Program-Implementation Plan II 2010-2015 puts a greater emphasis on mental health, which, according to the plan, reflects the changing burden of disease in Nepal, especially for women.
In 2009, suicide became the No. 1 cause of death for women of reproductive age, which may be related to the lack of power they feel in their lives and the high incidence of gender-based violence here, according to the plan. As such, the government is recognizing mental health as an important element of safe motherhood and adding mental services to the Essential Health Care Services package.
“Mental health problems are clearly widespread, and may be associated with the legacy of conflict and with the very high rates of violence and suicide, but it is less clear what can be done that will be effective within the resources that are available,” the plan states.
The government plans to implement one or more pilot projects before committing to a major expansion of mental health services, according to the plan. The project will start with training health workers in pilot districts on the basics of mental health, covering mental health issues in health education programs and integrating mental health within primary health care.
The government here introduced and implemented the National Mental Health Strategy in 1996. This plan aimed to ensure the availability and accessibility of minimum health services for all Nepalis, prepare mental health human resources, protect the fundamental human rights of the mentally ill and improve awareness about mental health.
Before that, the Ministry of Health and Population introduced a health-related second working policy from 1953 to 1958, which included mental health issues, says Leela Prasad Acharya, section officer for the ministry.
“Mental health has been prioritized,” Acharya says. “Now the government should consult the experts and should start on developing necessary laws and policies to solve the existing vacuum.”
Shrestha from CMC-Nepal also sounds optimistic.
“The need for special care and counseling already exists in the policies we have,” he says. “It’s just that they need to be executed. I am hopeful that the work policy introduced from 2010 to 2015 will get a head start.”
