Nepal

Nepal Poorly Equipped to Treat Women Who Suffer Depression, Anxiety When Husbands Work Abroad

Reacting to the pressure of added duties and fear for the health of their marriages, nearly 50 wives of migrant workers killed themselves in Nepal last year, underscoring the need to ramp up mental health services.

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Nepal Poorly Equipped to Treat Women Who Suffer Depression, Anxiety When Husbands Work Abroad

Babita Paudel (foreground) waits at her home in suburban Kathmandu for a call from her husband, Raju, who is working in Afghanistan. He usually sends her a text message to tell her what time he will call, so she checks her text messages frequently. Her niece, Muna Sunwar, 9, keeps her company as she waits for the call.

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KATHMANDU, NEPAL – On a warm evening, Babita Paudel, 30, awaits her turn outside the Meridian Health Care Center in Kathmandu, the capital of Nepal.

Paudel is dressed in traditional garb consisting of a pink kurtha and black surwal – a long, loose tunic worn over baggy pants.

She has come to the clinic to see a psychiatrist about her depression. While waiting to see the doctor, she calls her husband, Raju Paudel, on her mobile phone. He works at an electrical wiring company in Afghanistan.

“I don’t care about you or the children,” she says, weeping. “I do not want to take medication for depression. I don’t want to live. Let me die.”

Clearly upset, and responding in a loud voice, Raju Paudel can be heard from a distance as he seeks to calm her.

“Please don’t say that,” he says through the phone. “We also have a right over your life. Our children will be like orphans.”

This is not the first time Babita Paudel has called her husband and said she wants to kill herself, she says. It has become a routine: She calls her husband twice a day and threatens to commit suicide almost every time.

Babita Paudel has attempted suicide five times since 2010, she says.

She isn’t alone. Nepali women whose husbands work abroad are likely to experience depression and other mental illnesses, researchers and police officials say.

In their husbands’ absence, they must cope with the pressure of heading their families – a nontraditional role for women in Nepali society – as well as fear of their husbands having affairs while they’re away. The stigma surrounding mental illness prevents many women from seeking early treatment here, experts say.

Some government and nongovernmental agencies are attempting to raise women’s willingness to get treatment and to improve the quality and availability of mental health care in Nepal.

In fiscal 2012-2013, the most recent year for which statistics are available, more than 439,000 Nepalese men migrated overseas for work, says Badri Kumar Karki, spokesman for the Department of Foreign Employment, a division of the Ministry of Labor and Employment.

More than 3.2 million Nepalese men and women went overseas for work between 1993 and 2013, he says. The number of Nepalis migrating for work has risen by 15 to 19 percent each year.

The migration rate among men 18 to 40 began rising in 1993, says sociologist Ganesh Gurung, who specializes in Nepali migration issues.

Lack of jobs, decreasing agricultural production and political instability are driving the increase in migration, says Gurung, founder of the Nepal Institute of Development Studies, a nongovernmental organization that researches development issues in Nepal.

The country has seen a corresponding increase in mental illnesses among migrant workers’ wives, he says.

More women whose husbands work abroad are experiencing mental health problems, says Dr. Saroj Prasad Ojha, a psychiatrist at Tribhuvan University Teaching Hospital, a government hospital in Kathmandu. Ojha discovered the trend by working as a consulting psychiatrist for hospitals.

A study by the Center for Mental Health and Counseling-Nepal, a nongovernmental organization, confirms the finding. The study, the first of its kind, was conducted in two Nepali districts from November 2013 to May 2014.

The 126 wives of migrant workers surveyed in the study all exhibited symptoms of moderate or severe depression caused by separation from their husbands, says Pashupati Mahat, senior clinical psychologist at the Center for Mental Health and Counseling.

A diagnosis of mild to moderate depression means the patient has experienced symptoms such as loss of appetite, lack of energy, social withdrawal, and insomnia or excessive sleep for a significant period, Mahat says. Major depression, the most extreme manifestation of the disorder, is diagnosed when such symptoms persist for a long time and are accompanied by suicidal thoughts and physical ailments.

The complete findings of the study by the Center for Mental Health and Counseling will be published this month.

One of the main causes of women’s depression is the new role thrust upon them.

“After the head of the family migrates to a foreign country, the wives are responsible for managing the household,” Ojha says. “Separation from the husband causes mental pressure and financial and societal problems.”

Babita Paudel agrees.

She was happy when her husband was with her, she says. But after he migrated six years ago, she began to feel lonely and had to bear the sole burden of caring for her sons, 11 and 9, and her in-laws, with whom she lives in Narayanthan, a suburb of Kathmandu.

Her husband’s family has farmed for many generations. The family grows vegetables, maize and wheat on a small plot of land in Chitwan district, about 200 kilometers (124 miles) from Kathmandu.

Because the farm income – about 50,000 rupees ($519) a year – is insufficient to support the family, Raju Paudel looked for work overseas.

Raju Paudel sends his wife 60,000 rupees ($622) a month, just enough to cover household expenses, the children’s school fees, and the couple’s monthly loan payment. The couple borrowed a little over 1 million rupees ($10,000) to build the family’s home and cover the cost of Raju Paudel’s migration.

“The money management has increased tension in my life,” Babita Paudel says.

Her in-laws have made her life even more difficult, she says. They have accused her of inappropriate behavior.

“I never got happiness and satisfaction from my family,” Babita Paudel says, referring to her in-laws. “They started to raise questions about my character. They accused me of making plans to elope when they saw me talking with male friends and relatives.”

Babita Paudel’s depression deepened when her husband began accusing her of having affairs with other men, she says.

“Along with the feeling of anxiety, I started experiencing insomnia, difficulty in breathing, increased heart rate, tingling and burning sensation in my limbs, and also fainting,” she says.

Babita Paudel’s younger sister, Sabina Aryal, visits regularly. Aryal believes her sister’s illness results from the tension of living without her husband and being responsible for the entire family.

Aryal is not aware of anyone else in their family having struggled with mental illness, she says.

“She has attempted suicide many times,” Aryal says, “so someone has to be with her all the time.”

Babita Paudel most recently attempted suicide in February. She swallowed rat poison.

The psychiatry department of Tribhuvan University Teaching Hospital treats 60 to 70 women every day, Ojha says. Most are between the ages of 20 and 40.

About 20 percent of the migrant workers’ wives who come to the department are diagnosed with depression, he says. Others are commonly diagnosed with migraine headaches, gastritis, urinary infections and cardiac-related illnesses.

In addition to dealing with financial pressure, loneliness and heightened responsibility, many wives of migrant workers must cope with their husbands having affairs while they’re away, Gurung says. Married migrant workers often initiate sexual relationships with Nepalese women through social media sites.

Anita Giri’s husband has been working as a construction laborer in Saudi Arabia since 2009.

Giri, 27, started to suffer from insomnia soon after her husband migrated, she says. The mother of two girls, 10 and 9, she would stay up all night worrying about what would happen to the family if her husband fell ill or was injured on the job.

A year after her husband migrated, Giri says she discovered evidence that her husband was having an affair. The discovery heightened her stress and anxiety.

“I can’t sleep the whole night,” she says. “My heart beats faster when I think about my daughters’ future. If I did not have my daughters, I would have had killed myself already."

Giri’s husband used to send her more than 30,000 rupees ($311) a month, but now he only sends half that much, she says. She believes he’s sending the balance to the woman she suspects he is seeing.

Giri did not know why she was sleepless and feeling ill, or what she could do about it, she says.

That lack of awareness is a common problem among women, especially those living outside urban areas, experts say.

Giri’s relatives advised her to see a local shaman, or faith healer, because they believed an evil spirit was causing her insomnia, sad thoughts and lack of appetite, she says. She started visiting the shaman in March 2010 and followed the treatments he prescribed but did not feel better.

So in December 2010, she went to the Mental Hospital in Lagankhel, the only government hospital dedicated to the treatment of mental illness in Nepal. Giri, who lives in Bhaktapur district, travels 18 kilometers (11 miles) to the Mental Hospital in Lagankhel.

She was diagnosed with depression and prescribed antidepressants, Giri says. She continues to take medication for her condition but no longer receives counseling.

Ojha has treated many women who come to him as a last resort.

“Whenever women get mental illness, they go directly to the local shaman for treatment because they blindly believe in him,” he says. “They do this because they believe their illness is due to an evil spirit.”

When Babita Paudel began feeling depressed and anxious in 2008, she likewise visited shamans, as well as an astrologist, she says. She too feared that an evil spirit possessed her.

But her symptoms worsened, and she started having dizzy spells and fainting, she says.

In December 2010, Babita Paudel went to a psychiatrist in Kathmandu. She was diagnosed with chronic psychosomatic disorder, a condition in which psychological stresses adversely affect organ functioning to the point of distress.

Babita Paudel visits the hospital regularly to meet with her psychiatrist, she says. She has seen the psychiatrist each time she has attempted suicide.

Fearing stigma if she acknowledges going to a psychiatrist, she tells neighbors and friends she is going to the hospital to see a cardiologist for treatment of a heart disease.

“I don’t want to share about my mental illness with other people because I am scared that they will insult me and call me a mad woman,” Babita Paudel says.

In Nepalese culture, mental health problems are not usually considered health problems requiring medical treatment, Ojha says. Most women either hide their problems or fail to recognize them as symptoms of depression and excessive anxiety.

Some seek medical help only when their problems become critical, he says. Others visit psychiatrists only after exhausting all other possibilities.

“Many migrant workers’ wives I treat ask me to keep their information secret,” Ojha says.

Giri travels to the Mental Hospital by herself. She fears that if others learn of her treatment, they will think of her as mad and avoid contact with her, she says.

“I don’t want anybody to come with me because they might talk about this with my family members and other relatives,” she says. “When I come to the hospital, I even lie to my landlord, saying I am going to meet friends.”

Ohja believes lack of awareness of mental health treatment – and fear of stigma – prevent many women from obtaining timely treatment.

“Time and money are lost when patients ramble to various hospitals, and their problems become chronic when they do not visit the psychiatrist on time,” Ohja says. “Many women have psychosomatic disorders, which transform to depression.”

Severe depression can be fatal.

Forty-nine women between 16 and 45 whose husbands were working abroad committed suicide in 2013-2014, according to the Nepal Police headquarters in Kathmandu.

The department began tracking the number in 2013 after officers noticed an apparent increase in suicides among migrant workers’ wives, police spokesman Ganesh K.C. says.

“These women do not seek treatment,” K.C. says. “They are ashamed by their symptoms and are not healed by local faith healers. They do not know about treatment and don’t get medicines also.”

Unfortunately, district hospitals and primary health centers have insufficient resources to diagnose and treat people with mental illnesses, Ojha says. This is particularly the case in rural districts.

“Mental health infrastructure is poor, and human resources are not sufficient to meet the need,” he says.

The Mental Hospital in Lagankhel has only 50 beds. It has a small staff of four psychiatrists, four general physicians and 15 nurses.

“So, it is very hard for the local people who live outside Kathmandu to get treatment for mental illness,” Ojha says. “There is neither government hospital nor the private clinic in remote areas of Nepal, where most of the men go abroad to work.”

The government has earmarked nearly 34 billion rupees ($350 million) for the health sector in the 2013-2014 fiscal year, says Tika Prasad Bhandari, director of the Foreign Employment Promotion Board of the Ministry of Labor and Employment. That represents 6.5 percent of the national budget.

However, less than 1 percent of the health care funding is allocated for mental health services. That has limited the work in this area, Ojha says.

“This is why patients have to live with the disorder,” he says.

The government formulated a National Mental Health Policy in 1996 to raise awareness of mental health problems and increase access to care.

Legislation to implement the policy was drafted in 2011, but Parliament did not pass it.

Nepal needs a government agency dedicated to planning, implementing and monitoring mental health care, says Ghanshyam Pokhrel, a public health officer working on mental health under the Logistic Management Division of the Ministry of Health and Population.

“Although there are policies related to mental health, the lack of skilled human resources and a leading agency has hampered the effective implementation of the policies,” Ojha says.

The government must take urgent steps to treat mental health problems resulting from foreign migration, Gurung says.

Some government agencies and nongovernmental organizations are undertaking initiatives to improve mental health services where possible.

In collaboration with the Ministry of Health and Population, the Center for Mental Health and Counseling has been running community health programs in 32 districts of Nepal since November 2013, Mahat says.

The program has trained 640 health care workers to treat mental health problems. These workers now diagnose illnesses and provide counseling and free medication at the government health centers where they work.

While the training has focused on mental health problems in general, it has addressed the particular mental health needs of women, including migrant workers’ wives, Mahat says.

Other government agencies are also addressing this need.

“The government has been providing a two-day orientation to foreign migrants, but the orientation has failed to bring together the husband and wife to discuss problems that may arise while maintaining a long-distance relationship,” Bhandari says.

Believing that relationship problems are the primary cause of mental illnesses among migrant workers’ wives, he is keen to organize classes for couples as a part of the migrant training.

“We will try to implement it as soon as possible,” Bhandari says.

Mahat agrees, saying he strives to empower the wives of migrants through counseling, including training in relationship skills, stress management, emotion management and development of structures that help them lower their stress and anxiety in difficult times.

Even with treatment, Babita Paudel struggles to cope with depression.

She feels the whole world is dark around her, she says. She still feels stress from her added family responsibilities. Further, she is always tired because the sleeping pills she has been taking are no longer effective.

Babita Paudel does not believe she will get better. She does not believe the darkness around her will go away.

“My mental illness is never going to end,” she says, weeping. “So it is better to die than to be alive.”

GPJ translated this article from Nepali.