Mental health challenges in Nepal include a high prevalence of co-occurring mental disorders like depression and anxiety that worsen chronic diseases. Only 10% of individuals with depression receive treatment due to stigma and a lack of resources. Suicide is a leading cause of death among women in Nepal. Screening tools like PHQ-9 have been validated in Nepal but opportunities remain to better integrate mental health screening and treatment into primary care through collaborative care models and leveraging community health workers and existing psychosocial support programs.
Mental health challenges in Nepal include a high prevalence of co-occurring mental disorders like depression and anxiety that worsen chronic diseases. Only 10% of individuals with depression receive treatment due to stigma and a lack of resources. Suicide is a leading cause of death among women in Nepal. Screening tools like PHQ-9 have been validated in Nepal but opportunities remain to better integrate mental health screening and treatment into primary care through collaborative care models and leveraging community health workers and existing psychosocial support programs.
Mental health challenges in Nepal include a high prevalence of co-occurring mental disorders like depression and anxiety that worsen chronic diseases. Only 10% of individuals with depression receive treatment due to stigma and a lack of resources. Suicide is a leading cause of death among women in Nepal. Screening tools like PHQ-9 have been validated in Nepal but opportunities remain to better integrate mental health screening and treatment into primary care through collaborative care models and leveraging community health workers and existing psychosocial support programs.
Mental health challenges in Nepal include a high prevalence of co-occurring mental disorders like depression and anxiety that worsen chronic diseases. Only 10% of individuals with depression receive treatment due to stigma and a lack of resources. Suicide is a leading cause of death among women in Nepal. Screening tools like PHQ-9 have been validated in Nepal but opportunities remain to better integrate mental health screening and treatment into primary care through collaborative care models and leveraging community health workers and existing psychosocial support programs.
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Mental Health Challenges
and Opportunities in Nepal
March, 2021 Systems-based Problem Solving • Is there a problem? If so, what?
• What already exists to address this problem?
• Is a new solution needed?
• What is a feasible solution?
Is there a problem?
2014 APA Report
• Co-occurring mental disorders (e.g., anxiety and depression) can worsen the course of chronic diseases, such as cardiovascular disease, diabetes, obesity, asthma, epilepsy, and cancer.
• As many as 70% of primary care visits are driven by patients’ psychological problems, such as anxiety, panic, depression, and stress
• In as many as 70% of individuals with depression, their depression goes undetected in
primary care
• Only 10% of patients will complete a referral to a mental health provider that is not co- located https://www.apa.org/health/briefs/primary-care.pdf Is there a problem?
Stigma • Pagaal
• Dimaag problems
• Not treatable
• Not real
https://www.portstluciehospitalinc.com/mental-health-stigma-what-is-it-and-why-should-you-care/ Is there a problem?
Suicide • 2008/9 Maternal Morbidity and Mortality study
• Suicide was the
LEADING case of death in women aged 15-49 in Nepal
http://www.dpiap.org/resources/pdf/nepal_maternal_mortality_2011_04_22.pdf Is there a problem?
Chronic disease and mental health in Nepal
• 40% of patients with DM have undiagnosed depression
• 15% of patients with HTN have undiagnosed depression
• “Idioms of distress” – back pain, saato loss, gastric, etc.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3819627/ What already exists?
Globalized goals • Nepal spends 1% of healthcare budget on mental health • US spends 5.5%
• DFID (Dept for Int’l Dev) PRIME (Programme for Improving Mental Heath Care) from UK - improve coverage and treatment for priority mental disorders by implementing and evaluating a comprehensive mental health care package, integrated into primary health care in five countries (Nepal, India, South Africa, Ethiopia and Uganda)
• mhGAP Initiative from WHO
• Non-profits – Possible/Nyaya Health
What already exists?
How do PCPs address mental illness
• Training
• In-practice screening/diagnosis
• Treatment
• Consultation/referral What already exists?
Systems Assets Map
• Regional history of innovating mental health delivery – Charikot Hospital
• Dept of Psychiatry at Dhulikhel Hospital/Kathmandu University
• Available guidelines for diagnosing and prescribing
• Excellent primary care providers at Dolakha Hospital
• Excellent community health program
Is a new solution needed?
IRON TRIANGLE
Quality
Cost Access Collaborative Care
T – Team-based E – Evidence-based M – measurement-driven P – population-level Innovating in Primary Care • Patient Health Questionnaire (PHQ-9) • Started in the US in the 1990s • Based on DSM classification of Major Depression • Scores >10 are positive • > 80% sensitivity and specificity in the US
• Composite International Diagnostic Interview (CIDI)
• “Gold Standard” • WHO tool • Based on DSM criteria for MDD Screening Algorithm for Nepali Primary Care • PHQ-9 validated in Nepal • For score >/= 10 • Sensitivity = 94% • Specificity = 80%
• “Heart-Mind” problems • Yes or no? • Sensitivity = 94% • Specificity = 27% • PPV = 0.45, NPV = 0.98 https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-016-0768-y CIDT and Community Health • CIDT = Community Informant Detection Tool
• Pro-active case finding at the community level
• Can improve PPV to 0.68 compared to 0.42 by PHQ-9 alone
• narrative-based pictorial case identification to identify and refer patients to primary care
https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-016-0768-y Opportunities for the future • Develop clear role of behavioral health provider/team
• Protocolize an integrated/collaborative care model
• Set treatment and referral thresholds – focus on concrete algorithms
• Collaborate with DH psychiatry for consultation schedule and referral pipeline
• Utilize community health for referrals and targeted populations
• Didactics on mental health topics – emphasis on case studies
Questions/discussion! Also thank you for listening!
