On the day Binsa tried to end her life, it took two hours for her cousin and sister-in-law to walk her to the emergency room in Dolakha, a remote, mountainous district of Nepal just east of Kathmandu.
Binsa, whose name has been changed to protect her privacy, was 24 when her husband died in an accident. After her in-laws took away her young son to raise him in India, Binsa’s life felt empty and meaningless. When she reached the hospital, she met with doctors hired by the New York–and Nepal-based nonprofit ,whoreferred her to its peer mental-health counselors, located just down the hall.
Every morning and afternoon, SunitaJirel,a counselor who told Binsa’s story through a translator,worked with Binsaon calming techniques including deep breathing, meditation, and progressive muscle relaxation. With the help of another counselor, they addressed the reasons Binsa went to the hospital—trauma, anxiety, and suicidal ideation, among others—and the ways she might begin improving her mental health. The counselors also recommended that doctors prescribe two medications for anxiety and depression. After three days, Jirel says, Binsa was well enough to return home. She came back in a week to follow upand has returned every month or so for therapy sessions forthe past year and a half.
In Nepal, and home to only a of psychiatrists and psychologists, mental health care is vanishinglyrare. The Nepalesegovernment set aside roughlyfor all health care in 2019—compared to the U.S. government’s health budget—with less than 1percent dedicated to mental health.
Yet psychological conditions afflict Nepalis at higher ratescompared with the rest of the world. Researchers analyzing several recent studies on mental health in Nepal for the scientific journal found that more than one-third of Nepalis experience some issues with mental wellness, including anxiety (28 percent) and depression (30 percent). In comparison, about 7 percent of people worldwide haveanxiety disorders, and an average 3.2 percent of men and 5.5 percent of women experience depression. Nepalis also have a “high burden” of PTSD—nearly of the country suffers from the condition. In discussing these high rates, researchers pointed to a decade-long civil war that tore the country apart and a magnitude-7.8 earthquake that rattled it once more in 2015, as well as a lack of mental health care throughout the country.
The Nepalesegovernment set aside roughly $500 millionfor all health care in 2019—compared to the U.S. government’s $1.5 trillion health budget—with less than 1percent dedicated to mental health.
But despite the high prevalence of mental-health issues, there is still a stigma against seeking the appropriatecare in Nepal. “People with mental-health problems are generally poorly treated, pitied, and even despised in Nepal,” says Kul Chandra Gautam, former assistant secretary-general of the United Nations and author of (he also formerly servedon Possible’s advisory committee). “They are often seen as a burden to families and are ostracized by their neighbors.”
Possible Health, which now has more than 350 employees, launched in 2008 with a focus on chronic diseases, malnutrition, and maternal and child health in Achham, a region hit hard by the civil war. Itlater added mental health care, in 2016. Immediately after the 2015 earthquake, the nonprofit expanded primary-care offerings to another hospital, in Dolakha, where the majority of health-care facilities were damaged or destroyed by the quake. Although Possible always plannedto addmental health care at the hospital, the earthquake made this need more urgent, and itstarted offering services in 2017, shortlybefore Binsa arrived.
According to Gautam, the nonprofit opened at a time when mental health in Nepal was still beingneglected. “It is a completely unaddressed issue we have to conquer. We simply don’t have enough mental-health specialists in the country—even in urban areas and major hospitals,” he says. “Mental health has not been a government priority, given other pressing priorities.”
While the World Health Organization and other nonprofits recommend integrating mental health care into primary care, that often meansphysicianssimplyprescribe medications for anxiety and depression. Possible’smodel is unique for the country because itoffers psychosocial counseling under the same roof. And those counselors speak with psychiatrists every week about each case, to help them catch mistakes orsomething they might have missed. No other program in Nepal doesthat, saysBibhav Acharya, a psychiatrist and cofounder of Possible.
There are only 54 psychiatrists and psychologists in the entire country, says Acharya, and many doctors in Nepal receive no psychiatric education at all.
Acharya says thatimproved mental-health services have been a “silver lining” of the 2015 earthquake, with the eventbringing international attention—and some funding—to the gaps in Nepal’s health care. There are only 54 psychiatrists and psychologists in the entirecountry, which has more than 28 million people, he says, and many doctors in Nepal at all. But experiencing the quake themselves helped improve thedoctors’ empathy. “They finally realized how scary it is to have anxiety, how scary it is to be traumatized, to witness death and loss,” Acharya says. A crisis like the earthquake—or, before it, the Maoist civil war—can uncover previously hidden and untreated mental issues, he says.
Addressing mental health as part of overall health care makes it easier for patients to find relief and for Possible toskirt around the difficulties associated with discussing mental-health problems in the country. For example, counselors avoidtalking outright about depression, which is still a taboo subject; instead, they focus onsymptoms, like sleeping problems or headaches. From therethe counselors can exploretreatment optionssuch astherapy and medications.
Typically, the two Possible counselors in Dolakha each see betweenseven to ten patients perday. Peer counselors undergo a six-month psychosocial training, and they keep in close contact with a regional psychiatrist, calling every week to discuss each patient’s case. The psychiatrist visits every three months for training and observation, but both of Dolakha’s counselors are from the region, which is helpful tounderstanding patients’ backgrounds and building trust.
In the future, Possible will train more community health workers, especially those able to go to patients’ homes and villages, to recognize and begin treating mental-health issues alongside physical issues. This yearit began operating a third hospital,in Achham. “The overall goal is to develop a blueprint for what remote health care delivery looks like,” Acharya says.
The counselors continue to work with Binsa, who has changed dramatically from the day she checked into the hospital. “She’s totally improved,” Sunita Jirel says. Binsa still has not been able to see her son, but recently she was able to speak with him on the phone. At her most recent appointment, she told the counselors that she now hasa reason to keep living. “She thinks that, no matter what the shortcomings are in her life, she will fight through them,” Jirel says. “She feels stronger.”