The silent epidemic

Going by World Health Organisation (WHO) data, Nepal ranks very high in suicide rates, with 15 people taking their lives every day, on average. The country ranks seventh in the world for suicide rates and also ranks third for suicide rates among women between the reproductive age of 15-49 years. With 24.9 suicides recorded per 100,000 people in 2012, the last year for which comprehensive WHO statistics are available, Nepal has the second-highest rate in Southasia, with only Sri Lanka having a higher rate at 28.8. Studies have also found that attempted suicides are up to 20 times more frequent than completed suicides.

Social stigma, lack of awareness and discrimination against those suffering from mental illness are detrimental to addressing the crisis. Inadequate research and reporting makes it even more difficult for mental healthcare providers to reach out to those in need. In fact, when a suicide does make headlines, it is often in the form of a sensationalised news item on a freak event. When a Grade 10 student in Sunsari district in eastern Nepal took her life after her favourite football team, Brazil, lost to Germany in the 2014 World Cup, it was seen as an odd occurrence. The story was played up more for its shock value than as a pointer to a wider societal issue. This kind of coverage that promotes sensationalism without any reference to underlying causes is counter-productive to efforts to address the high suicide rate in Nepal.

Matrika Devkota, chairperson of Koshish Nepal, an NGO that works on mental health, talks about the 'silent suffering' of people with mental health problems. Devkota himself had been affected by mental health issues; he spent over 10 years struggling with depression before an unsuccessful suicide attempt left him in a coma for 72 hours. When asked what the major problems surrounding mental health and suicide in Nepal are, he says that those who are suffering do not realise that it is a common ailment. Often considered a sign of weakness, many leave the condition unattended, citing fate or punishment for actions committed in a past life. Since suicide is illegal in Nepal, it creates more barriers and stigma for those who need help as unsuccessful attempts are unlikely to be reported. This limits the reach of mental health professionals, NGOs and researchers. To counter this, Koshish is trying to break down the layers of stigma, misunderstanding and prejudice that mental health faces through advocacy. As Devkota puts it, one of the major aims of Koshish is to 'normalise suffering'. Creating an environment where talking about emotional issues is not seen as a sign of weakness but strength would be a major breakthrough for mental health issues in Nepal.

He also highlights high levels of migration in Nepal, and the perceived lack of opportunities for those who stay at home. "Every 12- or 13-year-old you speak to and ask about their dream, it is to settle abroad. This is surely an indication of how things are here." Large parts of the country, particularly rural and hilly areas, suffer from a chronic lack of development. Healthcare, education and employment prospects are bleak more often than not. However, whilst poverty plays an intrinsic role, it is not the sole determining factor. This can be seen in the case of Nepal's eastern district, Ilam, a district with high economic and literacy indicators, which also sees a high rate of suicides. In an interview with the Nepali Times, Bhupal Khatiwada of the Namsaling Community Development Centre, which ran campaigns to raise awareness about mental health issues when the number of suicides escalated in the district in 2014-15, outlined what he thought was the kernel of the issue: the immense pressure on young men to leave home to go study or work abroad, and, ironically, the sense of isolation experienced by the older generations when they were being left behind.

This sense of alienation, combined with a lack of understanding of the finer points of mental health issues, has lead to untreated cases of depression. Whilst those with mental health issues may desperately need help, any admission of suffering can be seen as a sign of weakness and in certain areas this can affect the family's standing in society. This then turns into a horrible cycle – societal pressure can be a major cause of mental health problems and those same pressures and stigma can then act as a barrier to receiving help.

The lack of public awareness is exacerbated in a situation where no governmental framework and infrastructure is in place. The allocated budget for mental health treatment did not even make up one per cent of the total health budget in 2014-15. There is only one public psychiatry hospital in Nepal, the Mental Health Hospital in Lagankhel, Kathmandu, which provides only medication but no therapy or counselling. Though the need is more urgent in rural areas, the government does not offer mental health services outside of the capital. There is no support for those who survive an attempt to commit suicide. In cases of ingestion of poison, for instance, patients are discharged after being treated for poisoning and, then, returned to their pre-existing environment, which could have caused the depression to take root in the first place. All treatment processes are centred on a patient's physical condition, with no thought to counselling and other mental health services that should be provided to patients who need them.

While this situation is bad enough, it is worse for women and even more alarmingly, the situation appears to be getting worse. In the last 'Maternal Mortality and Morbidity' study, in 2008, suicide was the leading cause of death for women aged 15-49, while in the previous survey in 1998 it was only the third highest cause. In a 2011 report the Nepal Government's Health Sector Support programme stated that many women are driven to suicide by domestic violence, which makes the situation worse given their already low status within the family and larger societal structures. The study also mentioned that young women in arranged marriages, widows and post-natal women are particularly vulnerable: "women who are exhausted by multiple childbearing or have given birth to daughters may also feel suicide is the only way out. Women who have been trafficked are also high-risk group, because of the horror of their experiences and the social stigma they face on returning home".

Devkota shares a story that helps explain some of the deep-set suspicions and mistrust that surrounds mental health and counsellors. Following the earthquake in April 2015, a team of psychiatrists went to a village to offer counselling and trauma therapy. However, the villagers were affronted: they were not crazy or mad, they had merely been through an earthquake, so why would they need counsellors, they asked. Devkota highlighted that this lack of awareness is not limited to villages as people living in the cities, including him, are sometimes not diagnosed with mental health problems until a considerable amount of time has passed; Devkota, for example, was not aware that his depression was a medical issue until he was diagnosed after 10 years of suffering. However, despite the stigma, people are starting to accept help. Koshish has been running a programme in Bhaktapur and Tanahun districts providing counselling to locals. After the earthquake, the number of people looking for counselling increased five-fold.

In these sessions, Koshish offers counselling, consultation with doctors and also provides prescribed medication. Every week volunteers, accompanied by a doctor, are sent to speak with patients, their family and the community with two main objectives – first, to check up on the patient's general well-being, and second, to provide information to the community to counter the stigma that surrounds mental health problems and create a supportive environment for detection and therapy. Koshish provides medication where needed as expensive drugs can often be a reason to discontinue treatment. But this kind of advocacy appears to be the exception, rather than the norm in Nepal.

But before one can push for a policy change, there is a need for holistic data collation and analysis to understand the complexity of the situation. In this regard, it is not just Nepal, but most of Southasia that exhibits a lack of systematic documentation. A report by Dutch aid agency Healthnet TPO, published in 2013, states: "Although India and Sri Lanka's suicide data collection and reporting systems are substantially more comprehensive and regularised than those in the other Southasian countries, there is general consensus among suicide researchers in all countries that there is significant and possibly massive underreporting throughout Southasia. This is due to a complex constellation of factors including criminalisation of the act (except in Sri Lanka) and the associated possible legal consequences for survivors and family members of reporting a suicide." Clearly, myriad causes interlink to create a large number of challenges for those suffering from mental health issues, and for those attempting to alleviate them. A concerted effort is required to ensure these problems do not spiral into a widespread malaise that takes more lives.

~Maximillian Morch is a Kathmandu-based freelance journalist, who writes on political, developmental and human-rights issues in Southasia. He has contributed to the Himalayan News Express, the Diplomat, the Tibet Post and Republica.