Young People and Mental Health in Changing World

World Mental Health Day 2018

Adolescence is a crucial phase of a life in which a child transitions into an adult. It is a tumultuous period of rapid changes, uncertainty, identity formation, restlessness and curiosity. At the same time it is a very exciting time of self explorations, socialisation and adventures etc. The growing demands of modern times, changing values and expectations, shifting relationships, the shrinking space to explore oneself and rapid physical and mental changes put adolescents in the state of perplexity and may not be able to comprehend the changes properly. This may lead to the experience of stress from mild to severe. Seeking out avenues to channel out their frustrations and stress, they can develop unhealthy coping of stress which can lead to risky behaviours such as the use of drugs, alcohol, aggression, apathy towards others and even to suicide as well. The stress for some of them becomes too much to handle due to which they might develop mental health problems. In this
context, World Health Organization is celebrating this year’s World Mental Health Day on October 10, with the theme ‘Young People and Mental Health in a Changing World’.

Adolescent’s mental health status in Global Scenario

According to World Health Organization , 1 in 6 people are aged 10-19 years whereas mental health conditions account for 16% of the global burden of disease and injury in people aged 10-19 years. Depression is regarded as one of the leading causes of illness and disability among adolescents and suicide is said to be the third leading causes of death in 15-19 years olds globally. Half of all mental health conditions start by 14 years of age and three quarters by mid-20s but most cases are undetected or untreated due to stigma and lack of awareness in such issues. The consequences of not addressing adolescent mental health conditions extend to adulthood, impairing both physical and mental health and limiting opportunities to lead lives in adulthood with good well- being and full potentiality.

Scenario in Nepal

According to the report of Central Bureau of Statistics (2014), the population of adolescents make about a quarter of total population which stands at about 6.4 million. There are several issues that concern Nepali adolescents such as child marriage, child labour, migration, maternal mortality rate, sexual exploitation, trafficking, HIV AIDS , mental health etc . Adolescents in Nepal have huge risks of developing mental illness but the facilities of the treatment haven’t been focused on adolescents mental health solely. WHO ( 2006) reported that among 18 outpatient mental health facilities available in the country none of the health facilities are meant for children and adolescents only. But , in 2015, Kanti Children’s Hospital has opened a child and adolescent mental health outpatient ward to provide psychiatric treatment and psycho social counselling to children under 18 years. The rate of incidence of suicide among adolescents is alarmingly increasing every year. It has been found that suicide rate among adolescents jumped from 5% in 2005 AD to 15.7% in 2009 AD (Mishra, Shrestha, Poudyal, & Mishra, 2013) .

Dealing with Adolescent’s Issues

Having a mental health issue in the early age of life is not choice or conscious decision, it can be due to environmental or biological reasons. Though we might not control the happening of the mental health condition to a young people but we for sure can prevent its happening or at least deal with the issue in such a way that every mentally ill can live their life with dignity. Firstly and majorly, starting with conversation on such issues will be a help while dealing with adolescent’s mental issues, it will not only help to bring awareness but help adolescent to acknowledge and speak up in the initial phase will help in early detection and treatment. Likewise, making educational institutions, family and community aware and empower to deal with such issues will be another way to help young people live their with full potentially and productivity in this changing world.

References:

Central Bureau of Statistics . (2014). Population monograph of Nepal, Volume II.

Mishra, N., Shrestha, D., Poudyal, R., & Mishra, P. (2013). Retrospective Study of Suicide Among Children and Young Adults. J. Nepal Paediatr. Soc, 33(2), 110–116.

WHO. (2006). WHO-AIMS report on mental health system in Nepal. Kathmandu,Nepal. Retrieved from http://www.who.int/mental_health/evidence/nepal_who_aims_report.pdf

(The article was featured in Republica- https://myrepublica.nagariknetwork.com/news/young-people-and-mental-health-in-changing-world/ )

Why Can’t we have Luxury to say ‘I am not Fine’?

”Why can’t we have the luxury of saying – ‘I am not fine’ when we actually feel so: not fine and emotionally down?”

This question is haunting me for a week and it all started when I asked a friend of mine, who is an expert in Psychology:  How are you feeling? He clearly seemed to be feeling down and mentally unhealthy. But his – simple reply was ‘All good, I am fine’. I am sure he might not want to share it but my question is: Would he say the same if he had a headache or fever or fractured hand? I am sure, no!

When WHO has defined Health as ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity’; why cannot an individual has a luxury of saying ‘I am not feeling fine’ when they are in a low mood or feeling not good mentally?

 

No matter how much we try to advocate the change in awareness in mental well-being and how much we talk about our Emotional and Mental Health, unless we be true to our mental wellbeing and emphasize as it exactly like of Physical Health, it’s never going to be any different.

May be we are focusing so much on being strong and portrayal of Heroic figure or controlling our sadness, we force ourself not to speak up about it. May be we are teaching our kids to look stronger and not show our failures. So next time, if you are feeding your kid with these: make sure to remember: Health is the combination of Physical, Mental and Social-wellbeing and to fully function, you got to feel healthy in every ways.

Here are the few statements I tend to hear elders preaching or few songs expressing which I have reservation on. Watch it out, if you are doing the same next time:

  • If you are teaching your daughter – ‘Queen will always turn pain into Power’ or ‘Big girls don’t cry’. Stop right there, right then and there.                                                                                                                                                                                                                      If you feel happy or pleasure or excited or any other pleasant emotion, why cannot you feel suffocated or cry? Negative emotion is just another emotion. Tell them to Let it go, speak it out exactly like what you do with your positive ones.

  • ‘Sometimes all you can do is Chin up, Hold your tears and Move on’.
    But I ask you-Why?

Why should you ever do that if you feel like not doing so? Why can’t you have luxury to feel down and cry it hard if you wish to? Is there any crime in not feeling well, it’s your life and your have every right to feel anything you feel like. Let people know about it and seek help!

  • ‘All’s well that Ends Well (Or, In Hindi: Anta valaa toh sab valla)’.                                                                                                                                                                                                                Is it okay to suffer in the journey just with the hope of good end?
  • ‘Cowards Cry (Or, In Nepali: marda rudaina)’.

If you are saying so. Seriously?

Trust me, It’s okay to feel. You aren’t weak. Don’t let anyone tell you different.

  • ‘Its easiest to Pretend that you don’t care rather than to admit that it’s killing you’.

    I don’t think so. Pretending is never easy especially the thing you feel. Like John Lennon said my friend ‘One thing you cannot just hide is when you’are crippled inside’.  Also pretending does more harm to yourself.

Dear friend, the one-liners explaining how should you behave in Public or how should you control your emotions will remain in use in every language, in every culture and in every forms. We are brought up in the culture where expressing sadness or negative emotion is the sign of being coward or lazy or the sign of trying to get away from the reality. But psychological and emotion focused researches explains that being able to feel our feelings actually makes us stronger and more resilient. When we allow ourselves to fully experience our feelings, it actually help us sort out what we really want and think. Feeling helps outlef in a safe and healthy and we are actually less likely to act on them in destructive manner.

You can trust on psychological facts and figures that, it’s possible to feel hurt without acting victimized and feel anger without being destructive; it’s possible to feel fear without hiding and feel heartbreak without breaking down.

So when next time you are verbally feeding your kid or explaining your friend on how to behave or stop the sad feeling, think back and ask yourself: Would you do the same if he has bodily pain, would you still ask him to suppress the pain and tell him to be stronger?

I understand sharing can make one feel worse, but how can you say that without trying?. I am sure sharing your pain, insecurities, fear can be daunting sometimes; and here i am not saying it should be shared to every next person you see; but to the ones whom you trust and most importantly atleast to the counselor if you really want to be helped.

Since quoting John Lennon once again: ‘One thing you cannot just hide is – when you’are crippled inside’; so why try it when it’s going to do more harm then benefit, my friend!
Let it out!

 

 

The power of activity: Nepali mental health patients find purpose in occupational therapy.

– Jenny Joyce, Kripa Sigdel and Sujan Shrestha

world ot day 2017

In the sunlit courtyard of a mental health residential facility in Boudha, Katmandu, men and women sit drawing and painting hand-crafted paper balloons, decorating the entrance to the 100-bed Amrita Foundation Nepal building.Patients here are on a journey of recovery from various mental illnesses.“When I’m drawing, I’m not inside my own mind anymore” says one of the men who regularly suffers hallucinations.

Nepal is still emerging from the devastation of an earthquake in 2015 that killed at least 8,000 people and left over 700,000 homes destroyed.Adding to a litany of challenges that already face the country  – crushing poverty, a decade of insurgency and continuing political instability – incidents of mental health problems appear to be on the rise since the earthquake. There are reported cases of increased suicide rates in the districts worst hit by the earthquake like Sindhupalchowk. While no official data exists on the prevalence of mental health illnesses estimates suggest around 20 to 30 percent of people in Nepal suffer some form of mental health problem.

Significant strides have been made in decreasing infant and maternal mortality rates and improving access to health services. Sadly the same cannot be said for the realm of mental health. It is perhaps the most neglected health issue in Nepal, demonstrated by the government expenditure of less than 1% of the health budget on mental health and the existence of only one government-funded mental hospital.It is alarming that Nepal was ranked 7th in the world for its suicide rate, according to the World Health Organisation in 2014.

Occupational Therapy

Amrita Foundation Nepal in Boudha is a privately-run mental health facility where patients suffering from illnesses including bipolar disorder and schizophrenia attend therapy sessions including some run by occupational therapists from the United Kingdom. Occupational therapy, sometimes called “OT”, aims to improve physical and mental health through engaging individuals in activity.Routines of everyday life like cooking and washing as well as leisure pursuits such as sport and music are activities that “occupy” our lives and help give it purpose.

Occupational therapists believe that a person who cannot participate in these activities because of a mental or physical ailment cannot achieve their potential and can find themselves left behind by society. Enabling people to regain and maintain crucial life skills is vital to a successful recovery from ruptures in life like family break-ups and natural disasters.

OT is a well established health profession across many countries globally. In Nepal, however, it is still in its early stages and OT practitioners are a rarity amongst the health and social care facilities around the country. The Association of Nepal’s Occupational Therapists set up in 2008 is working to promote the profession and raise awareness. Their efforts connect international occupational therapists working in Nepal with Nepalis who have sought OT qualifications abroad and returned to practice at home.Until now no educational programmes for training occupational therapists have been established in Nepal.

Wakeup Call

The earthquake in 2015 served as a wakeup call for both the government and the public to acknowledge the importance of mental health. A deluge of programs launched by NGO s and INGOs are seeking to address the growing needs of earthquake survivors suffering emotional and mental turmoil. It is essential to exploit this newfound awareness to bring about a more sustainable approach to mental health in Nepal. Positive changes are happening. The government for the first time has allocated a portion of the budget to implement mental health programs in different districts, work that is mainly being carried out by NGOs. In addition a new mental health policy has been drafted which is expected to address the gap in mental health delivery in the country.

One of the biggest challenges faced by Nepal is ensuring that all aspects of mental health care are integrated rather than only pursuing medical or biological treatment. Occupational therapy fits in this holistic perspective of mental health which can play a major role in helping the recovery and adjustment of mentally ill people.

On Friday, patients at Amrita Foundation Nepal will gather in the garden and build a tree sculpture to mark World Occupational Therapy Day 2017 which celebrates the profession internationally. Recently one of the patients at Amrita explained how living with depression and having nothing to do meant that “days are long but months and years slip by fast”.

To ensure patients like him do not pass through life feeling this way and to enhance the quality of life for mental health patients alike, it is crucial to provide opportunities for people to be occupied.

( Jenny is a occupational therapist from London )

The article was featured in Republica on 27th October, 2017. To see the online edition of the article in Republica click OT DAY 

Mental Health at Workplace

-Sujan Shrestha and Kripa Sigdel

break_from_work

In today’s busy world human life has been reduced to mere mechanistic ritual of making a livelihood. Every adult’s life is subsumed by the conundrums of their work which after some times have the greater likelihood of being monotonous. Being in the constant pressure of workload, deadlines, pleasing the boss, yearning for extra buck and recognition among colleagues can be deterrent for our mental health. In this context, to make us all aware of the work related stress and its impact in our mental health World Health Organization (WHO) has decided to celebrate this year’s world mental health day, October 10,  with the theme ‘ mental health in workplace’

Any work is better than no work?

Undoubtedly, it’s good for our overall wellbeing for us to be employed rather than staying idle. But, at the same time, negative working environment can be the potential stressor in life threatening our mental health. The recent study conducted by Chandola and Zhang (2017) in the UK revealed a quiet insightful finding. The study was done between the population who were re-employed in poor quality jobs and those who were unemployed. They found out that the population who were unemployed had lesser biomarkers of stress than those who were reemployed in bad working condition. This research has elicited the crucial understanding that any sort of job may not necessarily be better than no job. We need to focus on qualitative aspect of job rather than a job itself.

Cost of mental health problems

Negative working condition is very stressful for employees. This stress results from many sources. Some of the chief sources are: workload, inflexible work schedules, poorly managed shift works, intrapersonal conflict, low participation in decision making, job insecurity, poor pay, low social relationship, conflict with supervisors and managers, bullying and harassment etc. All these factors can lead to mental health problems such as burnout, anxiety, depression , substance abuse and some may even resort to suicide. All these have downward effect on the productivity of the job.  As per WHO, depression and anxiety have been attributed for costing global economy US$ 1 trillion each year in lost productivity.

One of the glaring evidence in Nepali context has been the news of suicide of those who went for foreign employment in Middle east countries, Korea and Japan. The report, “When the Safety of Nepal Migrant Workers Fails” published by International Labor Organization (ILO) in 2016, attributes suicide as being responsible for  about 10 % of all the deaths in foreign employment. The report compiled the number of deaths from the year 2008 -2015. Out of many reasons we can speculate negative working condition, work related stress and job dissatisfaction having contributory causal role to the suicide .

People with mental health problems have been suffering doubly. On top of their detrimental condition they have to bear the brunt of social stigma. They are seen as unfit for work. First of all we shouldn’t conceive ‘mental health problem’  constituting complete derangement of mental state and being out of reality only as demonstrated by the derogratory terms such  as ‘bahula’  and ‘pagal’. Infact majority of the people have mental health problems not exhibiting the symptoms of psychosis and they appear to be functioning well professionally. Due to the fear of stigma many people keep mum about their conditions in the workplace which will ultimately worsen their conditions

Protecting rights

Nepal is a signatory of The UN Convention on the Rights of Persons with Disabilities (CRPD). Article 27 of The UN CRPD provides a legally-binding global framework for promoting the rights of people with disabilities (including psychosocial disabilities). Similarly The Constitution of Nepal, 2015 enshrines the fundamental rights of all Nepali citizens regardless of disabilities. But still there are provisions in the law which debar the people with mental health problems from taking official responsibilities assuming the mental and cognitive incapacitation. The legal provision is vague in stating the mental state that constitutes mental and cognitive incapacitation but has sweeping generalization that puts all the mental health conditions in one basket. The government should amend the flawed laws which cast out the persons with psycho-social disability from workplace.

Majority of workplaces in Nepal do not have an insurance scheme for the health of their workers let alone for mental health. The attitude of co-workers and manager are not favourable to the employees who are facing mental health difficulties. There’s a need for understanding of such problems which can happen to anybody at anytime and not make it as a taboo. An environment of safety and security should be created for the employees who are facing mental health problems.

Nepal has recently introduced The Sexual Harassment at Workplace Prevention Act, 2015 which aims at preventing sexual harassment in the workplace, protecting the victims and punishing the culprit with the fine upto Rs. 50000 and six month imprisonment. Such laws should be introduced to prevent other forms of workplace harassment such as bullying. The organization should have non-discriminatory policies for their employees and have punitive provisions for the harassment and bullying and protection for vulnerable employee.

What needs to be done?

An organization can start with hiring a industrial psychologist or counsellor who can provide regular counselling services for the employee. Any employees can be benefitted by such facilities regardless of their mental condition and can be effective shield against any mental health problems. The management should be sensitive enough to understand the problem and accordingly design the job flexibly for employee with mental health problems and have supportive and confidential communication.

In terms of working condition we might be surprised to know that workers value more intrinsic motivations such as good relationship with supervisor, praise, respect, recognition than extrinsic motivation such as pay rise, bonus, good physical setting etc. This has been proven by famous study known as ‘Hawthorne Studies’ which compared the workers in different working conditions and  found productivity to be increased when the supervisor – worker relationship was good  than when physical conditions such as lighting, pay , breaks were increased. Therefore, good management and worker relation can improve the productivity and at the same time make positive working condition.

Employees should be aware of their own self care for one’s own physical and mental health. Regular physical exercise, plentiful rest, sleep and hydration are simple yet very effective for good mental health. Employees self care can be complimented by the organization by making good and flexible job designs and motivating the staff. One simple exercise of periodic group supervision in which members perform some rituals such as mindfulness exercises, share their highs and ups in work and personal life can have therapeutic effect.

While we are busy in making a living let’s take break sometimes to live a life!

(The article was published on October 10, 2017 in Republica. Here is the link of the article in the paper – mentalhealth in workplace )

The injustice done by Parva

parva poster

Yesterday, I went to watch the Nepali movie  ‘Parva’ starred by Namrata Shrestha and Koshish Chhetri. Initially I thought it was a horror movie and anticipated to have some goose bumps and heartbeats racing over the scenes. And frankly there were some episodes of that anticipation of the horror but my expectation of it being a horror movie completely took a downturn.  The movie touched my mind not because it has excellent storyline or because of the acting of the actors. It touched my mind because the issue it happened to showcase is the matter that is close to my heart or that I am more familiar with.  I am not here to review the movie.  I am writing this piece because I am troubled thinking the message that audience might be getting after watching the movie.

For those who haven’t watched the movie, it might be a spoiler alert. But I have to write this in the context of the movie and the roles of the actors to make my point.  So if you are planning to watch the movie, you might want to read this after watching the movie.

So coming back to the movie, the movie has circled around the issue of parent child relationship and its causal relationship to the mental health of a child. Up to this point I have not much to say about. But after this, the movie progresses into the sensational case building up. And this is where I have my serious concerns raised.

Without adding much suspense to the so called suspense thriller story, the movie revolves around the character of a severe depressive patient with psychopathic traits. In a nutshell the character likes to lure the girls who remind him of his mother and hacks them to death. The psychiatrist in the movie diagnoses the character to be suffering from childhood depression that progresses into full blown severe depression but is allusive of the diagnosis of psychopathy ( he gives the hint that the character might develop antisocial traits).

parva poster

The movie orients the audience about depression and the importance of parent child relationship in achieving mental wellbeing of children. But the tendency of the movie to associate depression with violence is the issue that I would like to object. I don’t know how much of study has been done to include such sensitive issue in the movie but from my movie experience ‘depression’ is sensationalised for pure entertainment gain in the movie.

Mental health issue itself is hugely stigmatized topic in Nepal. And people have this myth that people with mental illness are potentially violent and aggressive. And this movie has gone beyond to depict the gory violence of a ‘severe depressive patient’ which has reinforced the aforementioned myth about people with mental illness. The question here is what picture will the innocent audience will have of depressive patient after watching the movie?

It is already established fact that mental illness is neither a necessary cause nor a sufficient cause for violence. In Nepal we do not have official data to ascertain the exact percentage of people with mental illness involving in criminal activities. The comprehensive study done in the USA which was published in 1998 and famously known as MacArthur Community Violence Risk Study is a landmark study which studied the prevalence of violence among the discharged mental health patients from the hospitals.  The study found that  mentally ill people in general are no more violent than the normal population. And the subsequent studies have also supported this claim. There is a certain subcases in psychopathologies like substance abuse, antisocial personality disorder and in some cases of psychoses like in schizophrenia where violence can be observed in behaviours of the people. But in such cases also, the instances are very rare to establish violence as the effects of such conditions. It is exceptions rather than rule.   In fact there is a compelling evidence that most people suffering from mental illnesses are themselves the victim of violence. And tragically many people deprived of adequate treatment and support end of committing suicides, a self perpetuated violence.

Parva has insensitively made ‘mental health’ as bait to violence to make the movie a thriller genre. The takeaway from the movie is damaging to the psyche of audience who might correlate mental health problems with violence. The movie has only served to make the issue of mental health more stigmatized in the perception of the educated mass as this movie has been intended for the urban movie goers. This movie has done great injustice to the throngs of people who are suffering from mental health problems such as depression. It has needlessly and callously glamorised the ‘depression’ in such a way that there is a danger that people might tread the condition with caution and repulsion than empathy and emotional support which they actually need.

 

In Tribute To YamaBuddha

Suicide

“म फुट्छु तर झुक्दिन| दिन रात लड्छु सुत्दिन |”

The rough translation of these phrases tells about the wishes of a determined person who asserts that he would rather love to be broken than to give up. He goes on telling that he would fight the battle whole day and night but will never surrender.

These extracts are the part of a famous rap song that was brought to the Nephop fans by the popular contemporary rapper “YamaBuddha” few years ago. This and many of his epic rap compositions will forever make the scene of Nepalese music lively but the rapper himself is no more living with us. It has truly been disheartening news that someone as optimistic as YB can commit suicide (no doubt the contradictory speculations on his mysterious death still persist).

Let us take a dip into the emotional turmoil that this news had put YB’s fans like me into. Let us also unfasten few shackles that our society has attached to the suicides; for which few nuances of this problem have to be dealt with.

For me, suicides bring a long history of painful memories and partially solved emotional riddles. This event has once again exposed my vulnerability in processing the news related to suicides of people with whom I feel connected to. It’s a sad story to share but in these past 5 years, 5 cases of suicides have shaken my mental well-being quite brutally. I have witnessed 3 suicides in my college hostel, another one of my student last year and this recent one which have given me the most recent shock.

This time, I have realized that the new cases of suicides themselves are not the big challenges for me. The problem that I have recognized is the way I have handled my past mental upsets. When I went through cases of recurring suicides during my college, I forced myself to accept that nothing is so queer about students’ suicides as such suicides are quite common in India. Perhaps, the patriarchal mindset that commands every man to develop masculine attributes was also equally responsible for my artificial stone-heartedness during those days.

Yama budhha
source: ekantipur.com

Moreover, when someone popular as YamaBuddha who apparently didn’t have any reason to end his life, the million dollar question arises: why would anyone want to end his/her life in such a cheap way? What could be that one big factor that pushes everyone irrespective of their fame and wealth to the dark tunnel of death? I went through few of the stats about suicides both in the context of Nepal and in the world and the data was alarming.

What I have found has put me in more dismay as Nepal stands at the 17th place for most male suicides (30.1 per 100,000) and at the 3rd place for most female suicides (20.0 per 100,000). According to another estimate of WHO, almost a million people in the world end their life each year which accounts to more than the gross loss of lives lost in the global conflicts. This bleak situation both inside Nepal and in the global arena is mostly attributed to depression which is believed to be one of the most feared killers of humans after couple of other chronic diseases. WHO also reports that 350 million people globally suffer from depression, and estimates that, by 2030, depression will be the leading cause of global burden of diseases.

In this extended article, I therefore attempt to restate few of those old facts about suicide and depression. Below are few of the symptoms of depression which can trigger suicides or at least suicidal thoughts at some point in any individual.

  • Feeling sad for two or more weeks
  • Feeling completely drained and like you have no energy left
  • Unable to concentrate
  • Sleeping too much or too little
  • Eating too much or too little
  • Feeling worthless
  • Feeling hopeless
  • Feeling helpless
  • Feeling negative or pessimistic
  • Losing interest in activities that you previously enjoyed
  • Crying frequently
  • Withdrawing or avoiding social life
  • Neglecting personal appearance
  • Feeling angry
  • Feeling guilty
  • Unable to think clearly
  • Unable to make decisions

If these symptoms (not necessarily all of them) prevail in a person for more than 2 weeks then it’s possible that s/he is going through some depressive episodes. We might be going through these circumstances ourselves or may come across with some individuals who show these symptoms. The first and best remedy that one can offer is the emotional support. Avoiding lonely places and keeping oneself busy in one or other task will also help to an extent. But the ultimate support could be sought from the mental health professionals and one should not hesitate to reach out to these support centers. Gone are those days when society associated depression with the stigmas and mental illness as incurable result of some sins. If diagnosed and intervened in time, depression is just like other minor physical ailments and everyone can win the battle against it.

In a nutshell, if we keep ourselves emotionally vigilant to take on every challenges, then we can lead the life as described in an extract from the next renown song of YamaBuddha. With this phrase, he means “to persist on and not to give up is always greater than to win”

 “जित्नुभन्दा ठुलो हिम्मत नहार्नु हो | त्यसैले लड्दै छु , संघर्ष गर्दै छु |”

#RestInPeaceYamaBuddha