Psychiatry Overcomes Growing Pains at the Top of the World

Each time you read about the brain drain of physicians from the less-developed regions of the world to Europe or the United States, stop and think about young psychiatrists like Mona Thapa, M.D.

Thapa is from Nepal, and she intends to return there.

Thapa is a graduate of Nepal Medical College and is in her second year of residency at Howard University College of Medicine in Washington, D.C., working with department chair William Lawson, M.D., Ph.D.

In March, she gave a talk at Howard, in cooperation with the Washington Psychiatric Society, about the status of the mental health system in Nepal and later gave an extended interview to Psychiatric News.

A longstanding interest in human behavior and the need for more mental health clinicians in her home country led her into psychiatry. After training at a VA hospital in Washington, D.C., and then at Howard, she said, “Every moment has been satisfying.”

Nepal is not much different from many other poor, largely rural nations when it comes to mental health infrastructure.

Squeezed between India and China, Nepal seems like a tiny country, but it contains 26 million people and the tallest mountains on earth. Per capita income is about $1,000 annually.

The health system reflects those conditions too. There are fewer than 19 hospital beds and just 4.9 general practitioners per 100,000 population, most clustered around the larger cities and towns, as elsewhere in the world, said Thapa.

Until about 50 years ago, mental illness was highly stigmatized. It was considered a form of misfortune, and only faith healers provided help for mentally disturbed individuals. Psychiatric services began as an outpatient unit in a general hospital in 1961, and a five-bed inpatient unit was added in 1966.

The Nepalese government enacted a mental health policy in 1996 “to ensure the availability and accessibility of minimum mental health services for all.”

“But it needs to be revised,” said Thapa.

There are about 50 psychiatrists in the country, concentrated mainly in the capital Kathmandu and other cities.

“Mental health care is almost unavailable in other parts of the country, although psychotropic medications are widely available,” she said.

“One good aspect of the health care system in Nepal is a good network within the general health service system where mental health can be integrated,” she said. “There is a good family support system; sick family members are taken care of at home.”

Initially, psychiatrists had to go outside the country to train, but now there are about 10 residency slots within the country, and more are planned for the future. Not all graduating residents continue to practice in the field, however. Additional training programs are under way for psychiatric nurses.

The country’s single, 50-bed psychiatric hospital was built 25 years ago just outside the capital of Kathmandu, and it treats 850 inpatients and 23,000 outpatients a year.

“At least we had no asylums to get rid of,” said Thapa, in reference to the history of psychiatric care in Europe and the United States.

Most of the nation’s small mental health budget goes to fund the hospital, and the shift to a community-based model of care has been slow.

The 1996 mental health legislation, while a positive step, has not yet been fully implemented, said Thapa. The law sought to improve awareness of mental health, ensure the availability and accessibility of minimum mental health services, train more professionals, and protect the rights of mentally ill individuals.

A nongovernment organization, the Nepal Mental Health Foundation, advocates for implementing change in the mental health system and for patient rights.

One problem facing the country is the aftermath of a 10-year civil war fought between Maoist guerrillas and the government that ended in 2006, leaving at least 15,000 people dead and at least 100,000 displaced.

In one heavily affected district, for example, 60 percent of the soldiers, a substantial number of them children, had severe posttraumatic stress disorder (PTSD) symptoms, said Thapa. In addition, 33 percent of children who were never associated with armed groups had at least some PTSD symptoms.

“Those children are not now getting treatment,” she said. “We hope that new mental health policies will help.”

There is still no disaster plan in the country and no proper psychiatric management for these issues in place. A good starting point for improving the system would be a baseline epidemiological survey, she said.

When she returns to Nepal, Thapa hopes to use the expertise she is gaining at Howard in several ways. She would like to collaborate with agencies such as the World Health Organization or the U.S. Agency for International Development, which are involved with other aspects of health, on incorporating mental health concerns and basic treatment strategies into the care of mothers and children.

Thapa also sees a role for Nepalese psychiatrists in training primary care professionals in aspects of mental illness to help them recognize psychiatric disorders and provide basic treatment, she said. “We can have a more immediate result with that approach.”

Howard now runs a transcultural psychiatry program in Bermuda (Psychiatric News, February 4, 2011) that could serve as a model for Nepal, said Thapa.

Finally, she would like to work for not only the training of more mental health professionals in her home country, but also a better choice of available psychiatric medications and continued decentralization of the mental health system.