In the bustling outpatient department, Pana complained about dizziness and headaches to our clinician. “I have body aches too,” she added, rubbing her arms.

A set of questions unfolded. While diverting eye contact, Pana responded.

“No, it’s been a while since I slept well” as she twirled the end of her shawl on her finger. Updating her Electronic Health Record with a list of medications she has already tried, she was asked to go to room number 10.

Greeted by psychosocial counselors Geeta Raut and Bharat Kadayat, Pana seated herself in the enclosed white room. A warm noon, the sun poured in through the window as the counselors looked through her record. “What activities do you enjoy these days? Do you complete your house chores?” the counselors asked.

Bharat Kadayat, our Psychosocial Counselor In-Charge.

Pana is one of the 50+ patients who came with a mental health issue this week to Possible’s hospital hub in Achham District, in rural Nepal. Since the introduction of mental health services, patients with mental illness have been coming in, mostly complaining about physical ailments. In a culture where mental health is stigmatized, psychiatric illnesses masquerade as physical ailments and do not receive appropriate treatment.

“Achham has witnessed the history of Maoist insurgency. It also has alcohol related problems and a high domestic violence rate. Introducing mental health in this region was indeed of prime importance,” explained Dr. Jasmine Lama, our Implementation Research Manager.

Realizing the need to enhance clinician training in regard to diagnosis and treatment of mental health, Dr. Bibhav Acharya, Possible’s Co-Founder and Mental Health Advisor, introduced online lectures to all doctors and health assistants at our hospital. Not only is there a lack of knowledge and training about mental illnesses in Nepal, but there is also a severe shortage of psychiatrists in the entire country.

Dr. Bibhav Acharya with a patient.
Currently, it’s estimated there are 50 psychiatrists for a population of nearly 28 million, and even those are centered in major cities around the capital.

The option of referring every mental health patient to a specialist is also not feasible. “The closest psychiatrist for a patient in Achham is 14 hours away,” says Acharya. More often than not, patients do not end up seeking treatment because of the expensive and long commute.

Acharya added that severe mental illnesses like psychosis, bipolar disorder, and schizophrenia are very stigmatized, and most people can easily identify the behavioral problems in those illnesses. However, a high number of patients who may have that level of behavioral severity, like people with post-traumatic stress disorder (PTSD) and depression, can only be screened and recognized by trained clinicians. These patients fall through cracks in the contemporary healthcare system because they cannot be identified, and instead are treated with vitamins and painkillers for their manifesting physical ailments.

Photo: Sean Alonzo Harris

To provide comprehensive high-quality healthcare, all of Possible’s clinicians were taught to screen patients with mental health problems. Once the lectures on PTSD, psychosis, and depression were delivered, our psychiatrist Dr. Sikhar Bahadur Swar ensured the lectures were fully comprehended, while inculcating a high comfort level amongst clinicians to deliver mental healthcare.

“The workshop was very interactive. We prepped providers to practice new skills through role play before trying them out with their patients,” said Dr. Swar. It is not uncommon for medical providers to also harbor stigmatizing attitudes towards mental health patients, so interactive trainings are crucial in eliminating such attitude.

Moving the collaborative care model forward, Possible hired two psychosocial counselors. The clinicians identify mental health patients at the outpatient department, suggest medications, and refer them to psychosocial counselors who refer them back to clinicians after counseling. After reviewing the valuation notes from the counselors, the clinicians finalize the treatment plan, adding medications only if necessary.

Every week, the psychosocial counselors discuss the details of assessment and treatment plan for all new cases with our consultant psychiatrist, Dr. Swar. This program is starkly different from a traditional model of reactive supervision model where care providers enquire the consultant with what they do not know.

“This strategy of proactive consultation ensures that patients receive appropriate care,” said Dr. Acharya. “If we leave it up to recently trained clinicians to reach out with questions, we will miss many errors around diagnosis and treatment. This model also ensures that people who do not need medications don’t receive it. This type of collaborative care model has been shown to work very well in high-resource countries like the U.S. We are adapting and bringing it to rural Nepal.”

About 40 cases are studied over a couple of hours; this would have been impossible if the psychiatrist was examining the patient entirely on their own — making maximum utilization of a rare specialist in a setting like ours. The Community Health Workers then follow up with patients at their homes, ensuring they come for every appointment and do not run out of medicine.

“People are not aware about mental illnesses as a health problem,” explains Gita, our psychosocial counselor. The society shames the patients for their condition, and associates mental ailments with evil spirits or sins of past life, making them opt for shamans and traditional healers. Patients are even tied up because family members are unsure about how to control them.”

“…But every time a patient progresses, more patients from the same area come in. It’s a close-knit society, and when they see the patients improved and living a dignified life, more people are keen to recommend treatment at the hospital for conditions they previously thought were untreatable.”

The nearest psychiatrist may be 14 hours away, but our program is demonstrating that screening is important, and that high-quality treatment is possible by engaging a diverse team of clinicians, counselors, and an off-site psychiatrist to solve for the patient.

The next step is to take the services closer to home. Traveling to the hospital often takes days, and regular follow-up and counseling is critical to mental healthcare. Training the Community Health Worker Leaders to follow up on mental health patients at or near their home will ensure patients do not fall through cracks. Once the model has been optimized, it will then be implemented at Possible’s hospital hub in Dolakha, also the area critically affected by 2015 Nepal earthquakes.

Dr. Binod Dangal, Possible’s Medical Director in Dolakha, recently organized a visit from psychiatrists at our hospital hub. More than 25 patients visited, and most were diagnosed with acute psychosis.

Dr. Binod Dangal

“Adding to the post traumatic stress disorder of the earthquake and the reoccurring aftershocks are the problems of severe mental illnesses, common in remote areas of Nepal,” he explains.

Most healthcare delivery systems often ignore mental health because of the stigma associated with it, the lack of awareness about its severity and impact, and the absence of specialists to provide quality services. At Possible, we strive to provide the highest level of healthcare, solving for not just the absence of diseases—but also the promotion and adoption of a healthy lifestyle.

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