Binod Dangal, Rajesh Paudel, Dr Pradita Shrestha, Sunil Moktan, Sunil Khadka, Rashmi Dahal, Rajesh Ghimire, Bhupendra Gurung, Sunita Jirel
Dr Binod Dangal, MDGP consultant
Pashupati Chaulagain Memorial Hospital, Charikot, Dolakha
Mental health disorders are the leading cause of morbidity worldwide and the prevalence ranges from 4.3% (China) to 26.4% (United States) annually.Depression and anxiety were the third and ninth leading cause of disability respectively as per the 2015 global burden of disease study.Globally, 35-50% of people in developed countries and 76-85% people in less developed countries had not received any treatment in the past 12 months considering all cases of Mental, Neurological and Substance use (MNS) disorders which is a significant concern.
Nepal has 300 plus health facilities including hospitals and primary health centers but fewer than 200 psychiatrists and they remain highly concentrated in urban setting.High treatment gap for mental illness has been identified by national health survey of Nepal (2020).
With the total population of Nepal, more than 80% of the people live in rural areas where there is less access to mental health professionals. Due to less numbers of mental health professionals, task sharing approach is encouraged to scale up mental health care by global initiatives.World Health Organization (WHO) in 2008 initiated the mental health gap action program (mhGAP) in Nepal in primary health care to scale up for MNS disorders through training and supervision based on task-sharing approach. Due to high turnover of trained providers, lack of clinical monitoring and supervision of the program, lack of refresher training and of unavailability psychotropic drugs at health facilities, health centers are not able to provide effective regular mental health services.
Even with planned strategies of government, Nepal still faces higher burden of suicide day by day and Nepal secures 3rd position in suicide among women in the globe. And, almost 15-20% of patients visiting a health facilities have some forms of mental health illness. If new strategy is not started, we will face more complications of mental health disorders.
We are practicing new approach to manage mental health disorders in Pashupati Chaulagain Memorial Hospital (Previously Charikot Hospital). General Practitioners led collaborative care is a new model to address common mental health disorders in the remote setting. Our model consists of MDGPs, primary care physician (MBBS), psychosocial counselor and recently added clinical psychology service (Supported by CWIN). Strategy includes patients screening by primary care physicians and consultation with MDGPs and then reviewed by psychosocial counselor for assessing PHQ-9 (Patient Health Questionnaire-9), AUDIT (Alcohol Use Disorder Testing) scoring, PCL (PTSD checklist) scoring and psychosocial counseling depending on the case profile. We have tried psychiatrist led collaborative mental health care with the support of Nyaya Health Nepal (NHN) previously but the program phased out due to COVID-19 pandemic and other reasons.
We are treating with this model for more than 2 years with good follow up and good outcome to our patients. Our hospital has made attempts to cover supply chain in mental health drugs with collaboration with Curative Service Division (CSD). This might be a sustainable model as our country fulfills presence of more than 65% of MDGPs at district hospitals. Supporting MDGPs in need by psychiatrists would be a key factor to improve and sustain this model in longer run.
This article is written by Dr Binod Dangal who leads collaborative care model of Pashupati Chaulagain Memorial Hospital (PCMH), Dr Rajesh Paudel and Dr Pradita Shrestha, who are MDGP residents of NAMS (Bir Hospital), Dr Sunil Moktan, Dr Sunil Khadka, Dr Rashmi Dahal, Dr Rajesh Ghimire are PCPs of PCMH, Bhupendra Gurung is clinical psychologist and Sunita Jirel is psychosocial counselor.
