Nepali health worker's perspective on mental health

6 Feb 2014 - 12:00

Contributors: Nagendra Luitel, Pooja Pokhrel, Amit Makan

Bharat* shares his recent experiences of learning about mental illness through TPO Nepal and PRIME.  

Armed with 17 years of experience as a health worker in the public health sector, Bharat* recently completed a training program with TPO Nepal through PRIME, which has broadened his perspective and helped him to better respond to patients with mental illness.

* Not his real name

About Bharat

My name is Bharat* (name changed) and I am working as a Senior Auxiliary Health Workers (AHW) in one of the health posts in Chitwan. It has been almost 8 years since I have worked in this health post. I completed a Bachelor’s degree in health, and a 15 month course training to be a Community Medical Assistant (CMA). Professionally, I have been working in health sector since 1996, with my career beginning as a health professional in Bajhang, a remote district in West Nepal. I have had working experience in both rural and urban settings.

Mental health training offered to health workers

During the past 17 years of working as a health professional, I have attended several training courses, including child health, reproductive health, sexually transmitted diseases, amongst others. However, I never had the opportunity to learn about mental health. It was only last year that I attended a short training program on mental health organised by Transcultural Psychosocial Organization (TPO) Nepal as part of the PRIME initiative. The training helped me to learn about mental health problems, signs and symptoms, and to better understand the field in the local and global context.

How cases of mental ill-health were previously handled

We have received cases of mental health problems at our health posts before; however, due to a lack of knowledge and skills in this field, we were not able to support such cases. If severe cases were seen, or if someone with psychosis visited the health facility, we would refer them directly to the hospitals. And if anyone had complaints such as a headache, stomach ache, loss of appetite, tingling sensation in limbs, burning sensation in the body or disturbed sleep, we would provide symptomatic treatment by prescribing B-complex and analgesics. If anyone had suicidal tendencies or ideation, we were not able to pay much attention to such cases.

After attending the training offered by PRIME and TPO Nepal, I have come to the realisation that all these symptoms require serious attention, and should be dealt with carefully and sensitively. These days, if someone comes to me with problems such as loss of appetite or disturbed sleep, I take some time to better understand the problem in depth, which helps me to identify the core of the problem. Although I do not provide medication to everyone coming here, I do provide clear information about their problem and suggest that they take some measures to treat it, which has shown success. I also run a small clinic in the village on my own. When anyone with mental health complaints comes to my clinic, I provide them with basic psychosocial counselling and refer them to the health post for further treatment.

Changing negative perceptions of mental illness

There is a huge misunderstanding about mental health problems in the community and people with mental health problems are highly stigmatized, discriminated and neglected. Mental health is taboo, and people hardly discuss it. Those with problems prefer to hide their identity. In response to this, the training has enabled me to explain to clients and the community that mental health, like other diseases, is treatable and manageable. Currently, clients visiting our health post are easily accepting of the fact that they have mental health problems and are regularly coming for treatment.

Most patients are benefitting from medication and psychosocial support

I had never handled cases of mental health problems before. I had seen people taking lifelong medication and thought that they would not be able to function well once they quit the medicine, but the training has helped me to overcome such stereotypes of persons with mental illnesses. The successful cases in our health post have made it clearer. Some of our clients with depression have been able to recover after taking medicines for the prescribed period of 4-6 months. Those who were taking medication in the early months of last year have recovered, and have not returned to the health facility as yet - which is a very good thing. Similarly, our health services have also improved the condition of some of the psychosis patients in the community. In one case, the patient had been suffering from psychosis for the past 8-10 years. He was very aggressive and wandered away from home many times, eaten excreta, and also lost the ability to make simple judgments on what is right and wrong. After providing psychotropic medication available in our health facility, the medicine showed great improvement. He now stays at home, helps to carry out household chores and participates in social programs. This has been one of our greatest achievements. In the case of alcohol users, it is really challenging. We feel that we cannot do anything. As health professionals, we do motivate our clients to quit drinking but unless they are motivated themselves, it’s never going to happen. It has been very difficult for us to motivate our clients. Female counterparts of male alcoholic users sometimes seek a quick remedy for the problem, and when they do not see instant improvement, they are discouraged from returning to the health facility. Apart from these challenges, the program is going well so far. Our health facility not only provides pharmacological treatment, but also psychosocial support from which many have benefitted.

‘Health workers are now able to provide basic mental health services’

Usually mental health patients are treated by psychiatrists; however, through this training we, as health workers, are able to provide these basic mental health services. Psychiatrists have intensive knowledge about mental health as they are trained in this matter for many years. On the flipside, we are providing mental health services after only 12-15 days of training. Thus, at times it is difficult to identify cases if patients show symptoms that may be applicable to number of disorders. Mental health is a really sensitive issue. If side effects are seen whilst patients are using medication, we don't really have an idea how to manage them. At times, we fear that the community might question us about our capability. In addition, we are quite confused about prescribing doses to different age groups and to other special groups. Despite this, the psychiatrist conference that is held monthly has been of great help. The limited availability of medicines and its irregular supply has also been a problem. An interesting observation that I made during my work experience was that even the colour of the medicine strip has an impact on patients’. The colour of medicine strips that we provided previously is different from what we are providing now. This has resulted in mistrust. Some patients’ who have developed a disbelief in our services have stopped coming to the health facility.

‘With effective management and regular training, PRIME will make a contribution to the community’

Despite the shortcomings of the programme, the community is quite positive towards the services available in the program. Although it was quite challenging in the early stages, when people with mental health problems get better with our services, the community started perceiving us more positively. The Community Psychosocial Counsellors also shared with them information relating to mental health problems. Programs such as Control of Diarrheal Disease (CDD) and Acute Respiratory Tract Infection (ARI) that are integrated in health system have brought about positive changes in the community. After the program was launched, the mortality rate has reduced significantly. With respect to mental health, I believe that PRIME will make a similar contribution in the community. To further strengthen this program, management should be strong and effective, particular in the regular provision of medication. Aside from medication, more advanced training, including intensive disorder-specific training and refresher courses should be organized regularly with health workers.