An experience with depression in the remote far-west region of Nepal: salient features

by Dr Suraj Tiwari, Consultant Psychiatrist (under Ministry of Health, Nepal)

 

As a part of my regular postings under the Ministry of Health, I recently worked as a consultant psychiatrist in the Seti Zonal Hospital, located in the Kailali district. This hospital is the major tertiary referral centre for around eight other districts located around the Seti Zone. Here I got an opportunity to have an experience with depressive illness in the population, which may have some characteristics of their own.

The general population consists of people from wide variety of caste and culture. Most people live in the hills and have low socioeconomic status, the major source of earning being agriculture and migrant jobs. Their level of literacy level and awareness is also low. They have also seen and suffered the conflict during the Maoist revolution. People in general have plenty of myths and misconception about health and illness, and mental health and mental illness is no exception. During my stay in this region, I observed that mental illness is quite common, of which neuroses are the major chunk. After anxiety disorder, depression is the next most common mental illness, but often gets missed due to various reasons. Depression is seen in all grades – mild, moderate, severe; all ages – children, adults, elderly; all genders; all strata of society, and concurrent with or without medical condition. Most cases of depression are reactive to external events or secondary to other chronic medical condition like HIV, TB, DM, etc. Some are familial. Only few are endogenous.

These are the typical scenarios in people with depression: In the first one, depression is not considered illness at all. In this region, the mental illnesses, except the dramatic ones like psychoses, conversions, panic attacks etc. are usually not considered illness at all by the lay people. Therefore, depression may be wrongly judged as faking, fatigue, or punishment by spirits or gods/goddesses. This is mainly due to the deficits in education and awareness of the people.

In the second scenario, depression is considered a form of medical or physical condition. If depression is at all considered a form of illness, it may be misinterpreted as a form of physical or medical condition like general weakness, soft tissue injury, gastritis, and may be treated by vitamins, analgesics, antacids, etc. This is because depression often presents with somatic complaints like multiple aches, tingling sensation, burning sensation, heaviness, especially in people who come from the hills. Unavailability of health professionals trained in mental health is the main reason for inappropriate treatment in these cases.

In the third scenario, depression is rightly recognized as depression, and in a few fortunate ones, timely. These are treated appropriately by health professionals trained in mental health – paramedics, doctors and psychologists through the health posts, primary health centres, district hospitals, the zonal hospital and the regional hospital in the government system, as well as through the private hospitals and the NGOs. Most psychotropic drugs are available in the private sector. However, in the government institutions only a few items are available as free supply.

Surprisingly, psychotropic drugs are not the most preferred mode of treatment in this region for the mentally ill. Faith healing in the form of pujas by pundits, rituals by jhakris, remedies by astrologers is the most preferred mode of treatment, the practice and belief depending upon the caste and the culture. Often these are performed as the sole treatment, and many a times these are performed supplementary to the psycho-tropic treatment. Some people use the help of Ayurvedic medicine, homeopathic medicine, energy healing, etc based on their beliefs. These alternative therapies seldom prove to be sufficient to deal with depression as a sole treatment.

The very few health personnel trained in or knowledgeable about mental health and treatment are scattered in the primary health centres, district hospital, regional hospital and the zonal hospital, where most patients fail to reach due to geographical and financial barriers. However, a few from well-off families may travel to other cities in Nepal (Kohalpur, Nepalgunj, Kathmandu) and in India (Lucknow, Bareilly, Delhi), which may take a day or two. Those who travel to these cities do so not only for better and advanced treatment facilities, including inpatient facilities, but also to avoid stigma and discrimination faced in the local region.

There are some characteristic features about depression seen in this region.
A lot of patients are from hilly region and most are uneducated. Somatic complaints, which include multiple aches, tingling sensation, crawling sensation, burning sensation, headache, are a common category of symptoms in depression. Most people with depression do not complain of low mood and anhedonia, instead they complain of fatigue. However, most people do agree on those symptoms during the interview.
Most people with depression are usually not convinced that all their symptoms are due to depression. Some clients, however, would easily agree to take antidepressants, because not only they want to get better but they want to get back to work quickly. One problem during treatment is compliance. Most would reach remission in around 2 months, and would want to stop medications and keep insisting if they could shorten the course of treatment. Some cases are lost to follow-up, and most turn up after relapse. Not only non-compliance but also inadequate family support and overburdening work stress are factors for relapse.
Family support is inadequate in most cases because family members are away from home working in other district or abroad. Females are especially overburdened with work because they have to look after their husbands, children, other family members, house, cattle and farm.
Another factor for the relapse as well as non-remission is alcohol abuse, especially in the males. Cannabis abuse also contributes for relapse which is usually done for recreational purpose. By far poisoning is the most common mode of suicide, using organophosphorus which is readily available as a pesticide at home for their farm. The next most common mode is hanging.

The burden of depression is substantial.
The term depression is also used to mean any neurotic illness, i.e. mental illness except for the psychoses. However, depression is the most common illness after the anxiety disorders. Stigma is high for depression because it is misunderstood as a form of weakness of body or nerves or mind, punishment given by God for their sins
committed in this or past life, transmissible to the next generation in families. That is why most people with depression do not come for treatment. Some seek treatment with physician or other health professionals. Some go to treatment in far off places. Not all cases of depression may be difficult to treat, but most cases do not get
identified due to various reasons, the major ones being inadequacy of education and awareness in the general population, and inadequacy of knowledge and training in the health professionals regarding mental health and illness. Thus, education, awareness, and training should be the major interventions to decrease the burden of depression.

 

© 2017 Volunteering and International Psychiatry Special Interest Group, all rights reserved. Reproduction by permission only.