Public Mental Health in Nepal
Curriculum for Three-Day Training of District Public
Health Officers
Developed by Mental Hospital Lagankhel
with support from World Health Organization
Prepared by
Dr. Surendra Sherchan
Liana Chase, MSc.
Dr. Nawaraj Subba
Prepared in March 2017
Acronyms
CMH: Community Mental Health
CPSW: Community Psychosocial Worker
DPHO: District Public Health Office
FCHV: Female Community Health Volunteer
HP: Health Post
MH PSS: Mental Health and Psychosocial Support
mhGAP-IG: Mental Health Gap Action Programme Intervention Guide
MoH: Ministry of Health
NCDs: Non-communicable diseases
NGO: Non-Governmental Organization
SDGs: Sustainable Development Goals
WHA: World Health Assembly
WHO: World Health Organization
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Table of Contents
Introduction.........................................................................................................................4
Context.....................................................................................................................4
Public Mental Health Approach...............................................................................5
Training Objectives..................................................................................................5
Structure..................................................................................................................6
Looking Forward......................................................................................................6
Training schedule.................................................................................................................7
Curriculum...........................................................................................................................8
Day 1........................................................................................................................8
Greeting, Introductions, and Pre-Test.........................................................8
Introduction to Training– Objectives & Expected Outcomes......................8
Introduction to Health, Mental Health, and Mental Disorder.....................9
Importance of Mental Health– Burden & Impacts.....................................11
Overview of Priority Mental Health Problems............................................12
Mental Health: A Human Rights Perspective..............................................13
State of Mental Health Care in Nepal.........................................................14
Gaps and Challenges in Mental Health Care in Nepal................................16
Day 2.......................................................................................................................17
Recap of Day 1 & District Resource Mapping Activity.................................17
Social Determinants of Mental Health in Nepal..........................................17
Nepalese Model of Community Mental Health...........................................18
A Public Health Approach: Role of DPHO....................................................19
Public Mental Health Strategies: Logistics & Partners.................................20
Public Mental Health Intervention Models..................................................20
Public Mental Health & Disasters................................................................22
Film: Mental Hospital Lagankhel documentary...........................................23
Day 3........................................................................................................................24
Recap of Day 2 & Project Assignment .........................................................24
Project Preparation......................................................................................24
Small Group Presentations...........................................................................24
Concluding Session.......................................................................................24
Appendix I: Pre- and Post-Test.............................................................................................25
Appendix II: Video Content..................................................................................................26
Conclusion............................................................................................................................29
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Introduction
Context
Non-communicable diseases (NCDs) are emerging as the leading cause of death both globally
and in the South East Asia Region. Among NCDs, mental, neurological, and substance abuse
disorders account for 13% of the global burden of disease, and depression is among the leading
causes of disability worldwide. In many countries, the majority of people affected by mental
disorders do not receive treatment, and many additionally experience human rights abuses.
This has dire social and economic implications. The Sustainable Development Goals (SDGs) for
2030 include the promotion of mental health and wellbeing, the reduction of untreated mental
health problems, and the reduction of premature death from suicide. The World Health
Organization (WHO) and other global players have published several key plans and programs
that can help low-income countries achieve these goals.
In Nepal, limited progress has been made in developing mental health services over the past
twenty years. A national mental health policy was adopted in 1997. The numbers of specialized
mental health workers and hospital beds allocated for mental health patients have increased,
but remain grossly insufficient. Governmental and non-governmental organizations have
worked to develop the capacity of non-specialist health and psychosocial care providers;
however, these efforts have not been well coordinated or thoroughly evaluated. While training
curricula and service provision models tailored to the Nepali context exist, they have been
implemented in a piecemeal fashion, resulting in great variability in the availability and quality
of mental health services across the country. Additional challenges to achieving adequate
mental health coverage nationally have included lack of up-to-date mental health policy and
legislation, lack of a consistent coordinating body within the government, and low budgetary
allocation for mental health in Nepal.
In 2014, the Government of Nepal took a historic step when it included mental health as a
priority area in its Multisectoral Action Plan for the Prevention and Control of NCDs (2014-2020).
In 2015 Nepal was struck by a major earthquake, spurring further interest in mental health
among governmental and non-governmental stakeholders. The government has now drafted a
Mental Health Multisectoral Action Plan (2014-2020) and is currently revising national mental
health policy and developing a new action plan. Current and forthcoming action plans provide a
framework for achieving key targets by integrating essential mental health services into Nepal’s
primary care system. Within this framework the government’s existing network of District
Public Health Offices (DPHOs) will play a key role as the lead agencies on mental health at the
district level. The present training aims to provide knowledge and tools to public health officers
from all 75 DPHOs to enable them to effectively fulfill this role. As the first government-led,
nation-wide initiative to develop the capacity of public health officers in mental health, this
training represents a crucial step in building a national mental health system that addresses the
rights and needs of people living with mental health problems.
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Public Mental Health Approach
The WHO’s Mental Health Action Plan (2013-2020) embraces a public health approach to
preventing and controlling mental health problems. It calls for a comprehensive, coordinated
response from health and social sectors with an emphasis on promotion, prevention, treatment,
rehabilitation, care and recovery, as well as the development of relevant policy and legislation.
Mental health initiatives in Nepal have thus far focused mainly on treatment of those with
existing mental health problems. Relatively little attention has been given to the prevention of
mental health problems or promotion of mental health and wellbeing. Mental health issues
have also been neglected in social care programs, where there is often potential for a
significant public mental health impact.
Adopting this public health orientation, Nepal’s Multisectoral Mental Health Action Plan (20142020) designates DPHOs as the lead agencies on mental health in each district. In this role, they
have three main responsibilities. First, they must ensure that adequate essential mental health
services exist at the district level. This may involve organizing trainings and developing
appropriate supervision and referral mechanisms. Second, DPHOs are responsible for
facilitating public mental health programs that promote mental wellbeing, prevent mental
disorders, raise awareness, and reduce stigma and discrimination. Third, they are expected to
act as stewards of the mental health sector, managing resources and coordinating multisectoral
action. Involving the country’s existing network of DPHOs in this way represents a low-cost,
high impact approach to addressing mental health issues in Nepal. While other elements of the
comprehensive national mental health care system envisioned in Nepal’s Mental Health Action
Plan are not yet in place, we believe that DPHOs can creatively manage available resources to
begin this important work in their districts.
Training Objectives
By the end of this training, participants should:
 Know definitions of health, mental health, and mental illness
 Understand the importance of mental health, including the burden of mental health
problems and its social & economic implications
 Be familiar with national mental health policy and the rights of people with mental
disorders and disabilities
 Be familiar with key features of priority mental health problems
 Understand the scope and limitations of existing mental health services in Nepal
 Understand the principles of community mental health and its application in the
Nepalese context
 Know important social determinants of mental health problems
 Understand the role and responsibilities of the DPHO within a comprehensive national
mental health system
 Be familiar with public mental health intervention models and strategies that can use to
begin work in their districts immediately
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Structure
This training will be carried out over three days in three cities across the country: Biratnagar,
Pokhara, and Nepalganj. Each training will be attended by public health officers from 25
districts’ DPHOs. The first two days of the training introduce key concepts in public mental
health, issues and resources in the Nepali context, and public mental health strategies. The final
day gives participants the chance to brainstorm collectively about how to apply this training in
their districts.
Looking Forward
There is an urgent need to improve access to mental health services throughout Nepal. In order
not to lose momentum created by the recent earthquake and developments of the NCD action
plans, we have decided to proceed with the training of current DPHO staff in spite of the
ongoing federal restructuring process. Although this process may affect the boundaries of
Nepal’s districts, those trained will continue to be employed in the public health sector after
state restructuring, and thus will nonetheless be able to apply what they have learned. In the
future, we hope that this curriculum can be revised, lengthened, and integrated into the
standard training of all of Nepal’s public health officers.
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Training Schedule
9am-9:45am
Day 1
Greeting,
Introductions, and
Pre-Test
Day 2
Recap of Day 1
& Activity
Day 3
Recap of Day 2
& Project
Assignment
5 minute break
9:50am-10:35am
Introduction to
Social Determinants
Training– Objectives of Mental Health in
& Expected
Nepal
Outcomes
10:50am-11:35am
Introduction to
Health, Mental
Health, and Mental
Disorder
Project Preparation
15 minute break
Nepalese Model of
Community Mental
Health
Small Group
Presentations
5 minute break
11:40am-12:25pm
Importance of
Mental Health–
Burden & Impacts
1:25pm-2:10pm
Overview of Priority
Mental Health
Problems
2:15pm-3:00pm
Mental Health: A
Human Rights
Perspective
A Public Health
Approach: Role of
DPHO
Small Group
Presentations
1 hour lunch break
Public Mental
Health Strategies:
Logistics & Partners
Concluding Session
5 minute break
Public Mental
Health Intervention
Models
15 minute break
3:15pm-4:00pm
State of Mental
Health Care in
Nepal
Public Mental
Health & Disasters
5 minute break
4:05pm-4:50pm
Gaps and
Challenges in
Mental Health Care
in Nepal
Film: Mental
Hospital Lagankhel
Documentary
4:50-5:00pm
Closing
Closing
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Curriculum
Day 1
9-9:45am
Greeting, Introductions, and Pre-Test
9:50am-10:35am
Introduction to Training–Objectives and Expected Outcomes
 Trainers and participants introduce themselves
 Ground rules: turn off cell phones, respect for speakers, punctuality
 Discuss participants’ previous training in mental health
 Training objectives:
By the end of this training, participants should
o Know definitions of health, mental health, and mental illness
o Understand the importance of mental health, including the burden of mental
health problems and its social & economic implications
o Be familiar with national mental health policy and the rights of people with
mental disorders and disabilities
o Be familiar with key features of priority mental health problems
o Understand the scope and limitations of existing mental health services in Nepal
o Understand the principles of community mental health and its application in the
Nepalese context
o Know important social determinants of mental health problems
o Understand the role and responsibilities of the DPHO within a comprehensive
national mental health system
o Be familiar with public mental health intervention models and strategies they
use to begin work in their districts immediately
 Expected outcomes
Following the training, participants will be expected to:
o Organize mental health service provision
 Ensure that essential mental health care and ER services are available in
the community
 Assess human resources in mental health in their district and organize
further training or supervision as needed
 Assess referral mechanisms between psychosocial care providers, general
health workers, and specialist mental health care providers; establish
new or improved referral mechanisms as needed
 Organize monthly outreach clinic as needed
o Act as stewards of the mental health sector:
 Make contact with district-level and regional mental health organizations
and professionals; keep track of all ongoing mental health activities in
district and coordinate as needed
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Coordinate, collaborate with non-health sector actors (e.g. religious
groups, users and careers groups, community groups, NGOs, and the
social care sector)
o Plan activities that promote mental health and prevent mental disorders (at least
two in their districts each year)
Discussion activity: What are your experiences with mentally ill in your community or
district?
10:50am-11:35am
Introduction to Health, Mental Health, Mental Illness and bio psychosocial model of mental
health
 Definition of health: a state of complete physical, mental, and social wellbeing
 The field of mental health is concerned not only with curing mental disorders, but also
with promoting mental health and wellbeing
 Definition of mental health: a state of wellbeing in which the individual realizes his or
her own abilities, can cope with normal stresses of life, can work productively, can
relate with others fruitfully, can make a contribution to his or her community
o With respect to children, an emphasis is placed on the developmental aspects,
for instance, having a positive sense of identity, the ability to manage thoughts,
emotions, as well as to build social relationships, and the aptitude to learn and to
acquire an education, ultimately enabling their full active participation in society
 Attributes of positive mental health: positive self image, ability to adapt to changing
environment, autonomy, fruitful and meaningful social relationships, productive &
creative, resilient, compassionate and kind
 Impacts of positive mental health:
o Better health status
o Higher educational achievements
o Enhanced productivity and earning
o Improved interpersonal relationships/closer social connections
o Improved quality of life
 Some important concepts:
o “Mental disorders” refers to a wide range of mental and behavioral conditions
with the following characteristics:
 Involves changes in psychological activities of mind/brain
 Causes distress and suffering to oneself and/or to others.
 Leads to impairment in social, occupational, and family functioning
 The criteria for diagnosing different disorders are standardized in the
International Classification of Diseases 10 (ICD-10)– Classification of
Mental and Behavioral Disorders
o “Mental illness” refers to illnesses like depression and anxiety (also referred to as
common mental disorders) as well as schizophrenia and bipolar disorder (also
referred to as severe mental illness)
o “Disability” is an umbrella term for impairments, activity limitations and
participation restrictions denoting the negative aspects of the interaction
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between an individual with a health condition and that individual’s contextual
factors (environmental and personal factors)
 “Psychosocial disabilities” refer to people who have received a mental
health diagnosis and who have experienced negative social factors,
including stigma, discrimination and exclusion
o “Recovery:” From the perspective of the individual with mental illness, recovery
means gaining and retaining hope, understanding of one’s abilities and
disabilities, engagement in active life, personal autonomy, social identity,
meaning and purpose in life and a positive sense of self. Recovery is not
o synonymous with cure
Misconceptions about mental illness (causes, treatment, duration, etc.)
Biopsychosocial model of mental disorders - a modern view of the interaction of three
types of factors
o Biological: causes like genetics, neurochemicals, body constitution, physical
illness
o Psychological: causes like learning, coping, attitudes, childhood trauma, stress
o Social: causes related to social support, socioeconomic status, culture, violence,
disasters, abuses, etc.
Mental health care: many types of treatment exist for mental health problems; most of
them can be effectively managed or even completely cured.
o “Psychosocial support” usually refers to non-biological interventions for people
with mental health problems; this may involve addressing social or psychological
factors leading to disorders, or treating disorders through non-biological means
such as counseling
o “Mental health care” in this document refers to any type of local or outside
support that aims to protect or promote psychosocial well-being and/or prevent
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or treat mental disorder; this includes psychosocial support and
biological/medical interventions
11:40am-12:25pm
Importance of Mental Health– Burden and Impact
 Burden
o Prevalence: 1 in 4 in lifetime, ¼ of disabilities
o Importance of DALY in revealing burden of mental health including NCDs
o Mental health problems are major contributor to global burden of disease (13%)
 Depression is the single largest contributor to non-fatal burden
(disability) and fourth leading cause of disease burden (in DALYs) globally;
is projected to increase to second leading cause of disease burden in
2030
 1.1% of total DALYs lost are because of schizophrenia. 2.8% of total years
lived with disability are due to schizophrenia, since the disorder is
associated with early onset, long duration, and severe disability
o Drivers of increasing burden of mental health problems including NCDs:
globalization, urbanization, population aging, climate change, shifts in lifestyles,
changes in diet, social issues of inequality and injustice, lack of inclusive &
participatory system of governance, economic development, etc.
o In Nepal, NCDs account for 60% total burden of disease and mental health
represents an estimated 18%
o No national data exist on the epidemiology of mental health problems in Nepal,
though a study is under development
 Impacts
o Health: mental disorders often affect, and are affected by, other diseases such as
cancer, cardiovascular disease and HIV infection/AIDS. For example, there is
evidence that depression predisposes people to myocardial infarction and
diabetes, both of which conversely increase the likelihood of depression.
o Economic impact of mental health problems: reduced productivity,
disability/illness cost
o Social impact: reduced quality of life, happiness & productivity suffer
o Development: there is significant evidence that untreated mental illness
negatively affects economic development at a societal level
 Calls to action
o World Health Organization, World Health Report 2001– Mental Health: New
Understanding, New Hope
o Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) for scaling
up care for priority mental, neurological, and substance use disorders
o WHO's Mental health action plan 2013 to 2020.
o Sustainable Development Goals (SDGs) for 2030
 Video: “WHO: Introduction to Mental Health” (5.24)
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1:25pm-2:10pm
Overview of Priority Mental Health Problems
 Priority mental health problems in Nepal:
o Depression
 Key features: decrease in mood, interest and pleasurable feelings, and
psychomotor activities
 Lifetime estimate of prevalence for either major depressive disorder or
dysthymia is 4.2–17%
 Major cause of suicides & disability.
 Most common major psychiatric disorder
o Psychosis (schizophrenia and other psychotic disorders)
 Key features: gross impairment in reality testing by distortions in
perception, thinking, affect and behavior. Show abnormal talk,
inappropriate affect and abnormal behavior.
 Associated with early onset, long duration, severe disability
 Lifetime risk for schizophrenia is 0.08–0.44%.
 Prototype of major psychiatric disorder
 Most devastating & debilitating of all illnesses
 Great importance of early recognition and interventions
 Recovery approach
 Stigma & discrimination adds to suffering
 Importance of psychosocial care for people living with metal illness and
support for their families and carers
o Disorders due to use of alcohol & drugs
 Key features: abuse, dependence, mental health problems
 17.6% of adult population in Nepal consumes alcohol according to STEP
study
 Causes Delirium Tremens in dependent people
 Major cause of domestic violence towards women in the families
 Causes many physical and psychiatric problems
 Psychosocial support, treatment and care should be available for those
affected
o Dementia
 Key features: a progressive neurodegenerative disease associate with
gross decline in memory, cognitive function and global functioning of
personality
 About 24.3 million people have dementia worldwide, and this number is
predicted to double every 20 years
 Population pyramid upended in west
 Growing proportion of ageing population with increased life expectancy
in developing countries
o Mental disorders in children
 Key features: intellectual disability, developmental disorders
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The prevalence of intellectual disabilities (mental retardation) from
developing countries has been reported to vary from 0.09% to 18.3%.
(Nepal: 3 to 4%)
 Mental disorders in adults often begin in childhood or youth. Roughly
50% of mental disorders in adults begin before the age of 14 years.
 This is an area where public health approach can have the biggest impact
o Epilepsy
 Key features
 Generalized tonic-clonic seizures (GTCS) - episodic & brief attacks
with rigidity, fall, LOC, convulsions
 The prevalence of active epilepsy globally is 5–8 per 1000 population
 Epilepsy affects about 50 million people worldwide, about 80% of whom
live in developing countries
 Most common neurological disorder with many mental health and
psychosocial impacts.
o Suicide
 Suicide is the second leading cause of death in people aged between 15
and 29 years. Over 800,000 people die from suicide every year.
 Suicide represents 1.4% of deaths worldwide
 Suicidal attempt and suicide are considered illegal in Nepal (although the
law is ambiguous), which might prevent reports of suicidal ideation.
 Mental health problems are a major cause of suicide (not only
psychosocial causes)
 Males at higher risk overall, but among females 15-49 suicide is the
leading cause of death in Nepal
 Discussion activity: What beliefs do people have about suicide in Nepal?
o Anxiety and stress related disorders (e.g. anxiety, phobia, mass conversion
disorder)
 Key features: irrational fears and worries
 Prevalence: one of most common mental health problems
 Impacts on QOL, productivity
 Major health problem in modern times
2:15pm-3:00pm
Mental Health: A Human Rights Perspective
 International conventions and guidelines
 Alma Ata Declaration (1978)
 Called for primary care for all by 2000
 8 components of primary care included promotion of mental health
 Convention on Rights of People living with Disabilities (2006)
Rights include:
 Full inclusion and participation in community life
 Equal rights to work and gain a living
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Access to quality health care services as close as possible to people’s own
communities
 This is not a matter of charity, but a matter of human rights
o Human rights of people living with mental illness:
 Right to accessible and affordable mental and physical health care
 Right to independent community living
 Right to work and participation in social life.
 Right to be free from cruel, inhuman, degrading treatment
 Right to education and training available to other citizens
 Right to marry, have and adopt children
National policy and guidelines
 National Mental Health Policy (1997)
 Integrate mental health within general healthcare to make it available to
all
 Produce appropriate human resources required for mental health care
 Protect human rights of people with mental health problems
 Raise awareness about mental health and mental disorders in the public
 Currently under revision
 Mental Health Treatment and Protection Act
 4 drafts prepared (2001, 2006, 2012, 2015), but not passed
 New legislation currently being considered
 Mental Health Action Plan 2014 - 2020 under strategic Action Plan for prevention
and control of NCD exist.
 Mental health as a public health agenda
 The strategies are:
 Public mental health approach
 DPHO's lead role in mental health care of community
 Mental Health in primary care
 Comprehensive and integrated plan
3:15pm-4:00pm
State of Mental Health Care in Nepal
 Human Resources
As of 2017:
o Psychiatrists
 Have: 120 (1:250,000)
 Need: 270 (1:100,000)
 Deficit: 150
o Clinical psychologists
 Have: ~22
 Need: ~100
 Deficit: ~78
o Mid-level psychosocial care providers
 Psychiatric social workers qualified at graduate and master level
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Have: none, but in bachelor and masters levels social work
programs students can major in mental health
 Need: ~30
Community psychosocial workers (CPSW) and counselors trained by
NGOs
 500-750 (before 2015)
 National standardization and certification process is needed
o Nurses
 All nursing curricula contain some mental health components
 Masters-level specialized psychiatric nurses: a few
 Bachelors-level specialized psychiatric nurses: a few
 Deficit: great
Mental Health Care Facilities
o Number of hospital beds
 Have: ~800
 Need: ~2800 (10:100,000)
o Drug and alcohol treatment and rehabilitation services
 Methadone oral substitution therapy exists
 Government runs a few treatment and rehabilitation services for drug
users
 Most services for alcohol and drug problems provided by NGOs, but some
NGOs in this sector are notorious for human right violations; they may
not have adequate medical back up to manage life threatening
withdrawal of substances such as alcohol
o Rehabilitation for severely mentally ill
 NGO: Asha Deep
Psychotropic drugs
o Psychotropic drugs included in the national essential drug list
o Government intends to make these freely available, but gaps remain
Government sector resources: Mental Hospital Lagankhel, some zonal & regional level
government hospitals, and 3 of government medical college hospitals (IOM, BPKIHS,
PAHS). Military and Police departments have mental health service as well.
Private sector: 20 medical college hospitals with two psychiatrists and 15-bedded
psychiatric ward on average, and numerous nursing homes with mental health services
mostly in Kathmandu.
NGOs (e.g. TPO-Nepal, CMC, CVICT): provide much of the MHPSS services; involved in
developing community mental health services and training psychosocial care providers;
have produced 500-750 community psychosocial workers (community members with
brief training)
Non-Allopathic health system: Traditional healers, Ayurveda, Tibetan Medicine
Rights-based organizations: advocacy for mental health policy law and services (e.g.
Koshish, Mental Health Foundation, & others)
Informal sector: family, community groups, cultural & traditional practices (e.g., Osho,
Rajyog, Vipashana, Art of Living etc.)
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o Discussion: What mental health resources exist in Nepali culture and society?
4:05pm-4:50pm
Gaps and Challenges in Mental Health Care in Nepal
 Treatment gap of more than 85% for care and support of people living with mental
health problems
 Mentally ill people in JAILS for "criminal offences"
 People with mental illness in streets as homeless, many chained & confined
 Concentration of human resources in urban areas
 Lack of up-to-date mental health policy and legislation to address the needs and protect
the human rights of those with mental health problems
 Poor coordination among stakeholders (e.g. weak referral pathways between NGOs and
governmental services; failure to integrate mental health into safe motherhood and
early childhood programs such as the first 1000 joyful days campaign and non-health
government agencies)
 Lack of psychosocial care and rehabilitation facilities for the chronically mentally ill and
disabled
 Limited availability of essential psychotropic drugs
 Video: “Mental health situation in Nepal” (13.45)
4:50-5:00pm
Closing
 Select 2 participants who will give summary of day’s learning the next morning (one
each for afternoon and morning sessions)
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Day 2
9:00am-9:45am
Recap of Day 1 & District Resource Mapping Activity
 2 participants report what they learned the previous day
 Activity: What mental health resources exist in your districts? What mental health
programs and activities are already taking place? Please make a list and be prepared to
share with group.
9:50am-10:35am
Social Determinants of Mental Health Problems in Nepal
 Determinants of mental health and mental disorders include not only individual
attributes such as the ability to manage one's thoughts, emotions, behaviours and
interactions with others, but also social, cultural, economic, political and environmental
factors such as national policies, social protection, living standards, working conditions,
and community social supports.
 Exposure to adversity at a young age is an established preventable risk factor for mental
disorders.
 Risk factors for many common mental disorders are heavily associated with social
factors, including social inequalities
 In countries around the world, a shift of emphasis is needed towards preventing
common mental disorders by action on the social determinants of health
 Gender issues related to mental health status
o Domestic violence
o Witchcraft accusations
o Early marriage
o Polygamous marriage
o Widows doomed to remain single
o Chaupadi (confinement of menstruating women)
o Discriminatory laws
o *Suicide is the leading cause of death of women of reproductive age*
 Literacy and education level
 Poverty
 Migration (both within and outside Nepal)
 Other risk factors related to societal norms in Nepal: caste hierarchy, minority status,
LGBT identity
 Protective factors:
o Family, peer, and other social support networks
o Being married
o Higher education/literacy
o Having employment, livelihood
o Having good physical health
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10:50am-11:35 am
Nepalese Model of Community Mental Health (CMH)
 During the 20th century, mental health care was dominated by in-patient institutions;
human rights abuses were common and costs were high
 In the last few decades, there has been an important shift away from this model
towards the provision of care in communities, or CMH, with very limited long stay
facilities and high reliance on non-specialist health workers
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Why CMH is appropriate for Nepal and how it can help address the treatment gap
o Feasible: does not rely on specialist resources, which Nepal has a shortage of
o Cost-effective: utilizes existing community, health & social sector resources
o Non-stigmatizing: care at primary health facilities rather than separate mental
health facilities
o Protects the rights of people with mental health problems to live a meaningful
life in community
Elements of Nepalese model of CMH, which has been developed through the work of
different institutions over the past 20 years
o Involvement of Female Community Health Volunteers (FCHVs; grassroots level):
should receive at least 1 day of training on how to identify and refer people with
common mental health problems, and should be responsible for reporting on a)
completed suicides, b) mentally ill living in the streets/ in confinement
o Community psychosocial workers (CPSWs; middle level): recruited from local
community and given in-service training; responsible for a) providing basic
counseling, b) helping clients access existing government social benefits, c)
mental health education of client and family, d) crisis management (e.g.
facilitating hospital admission when necessary), e) ensure availability of essential
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drugs, f) support finding and sustaining work, and g) support finding
housing/accommodation, among others
o Primary health care workers: receive some training in mental health so that they
can identify, provide basic care for, and refer cases of mental illness as needed;
provide emergency care; must have adequate supervision and clear referral
system
o Outreach program: at least once a month each district should be visited by
psychiatrist from the nearest hospital where there is a psychiatry department;
the purpose of this visit should be to train and supervise general health workers
and assist in complicated cases (NOT to see all mentally ill patients)
o Self-help groups of service users and families/carers (organized and sustained by
DPHO)
o Links with other stakeholders (e.g. social sector, community organizations, nonhealth governmental organizations, etc.)
Video: “Democratizing mental health” (9.20): PRIME project as case study of integration
of mental health services into primary care system
11:40am-12:25pm
A Public Health Approach: Role of DPHO
 Overview of public mental health approach advocated by WHO in World Health Report
2001
o Provide treatment in primary care
o Make psychotropic drugs available
o Give care in the community
o Educate the public
o Involve communities, families and consumers
o Establish national policies, programmes and legislation
o Develop human resources
o Link with other sectors
o Monitor community mental health
o Support more research
 Importance of public health approach to mental health: resource-efficient, high impact
 DPHO should act as the lead agency for mental health in the district. This role
encompasses three levels:
o Ensure adequate individual-level services: manage/organize treatment, care, and
rehabilitation services
 Arrange in-service training of general health workers from district
hospital, PHCs, HPs on mental health
 Arrange for training of mid-level community psychosocial workers
 Orient FCHVs on mental health issues and their responsibilities (identify,
refer, report)
 Organize monthly outreach program with nearest mental health team
o Provide population services: campaigns, awareness programs, screening
programs
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 Conduct at least one promotive and one preventive activity per year
o Take intersectoral action: DPHOs acts as stewards of mental health sector;
should take a leadership role in coordinating multisectoral collaborations,
advocacy for improved policy and legislation, and mobilization of resources from
private, NGO, governmental (health and non-health) sectors as well as the
community
 Develop, strengthen, and sustain self-help organizations of service users
and their families/carers
 Make sure livelihood, safe motherhood, and early childhood programs
include or prioritize mentally ill and disabled
 In some districts the local department of women and children has
allocated space for a psychosocial counseling center
1:25pm-2:10pm
Public Mental Health Strategies: Logistics & Partners
 Logistics
o Financing mental health programs: rather than depending solely on funds from
the federal government, DPHOs can seek additional support from the local
government, private organizations, philanthropic individuals and organizations,
and NGOs
o Planning programs: When planning for year’s activities, add budget line for at
least one promotive and one preventive public mental health activity; consider
when and where you can hold programs to reach target audience, e.g. organizing
during festivals and other community events can increase exposure
o Organizing through partnership: think about how you can mobilize existing local
resources within your programs, for example, you may involve mothers clubs,
community leaders, religious organizations, etc. in planning or carrying out
activities
 Partners
o Mental health NGOS and community organizations: these can act as valuable
resources in training or preventive/promotive programs; e.g., you may involve
mental health NGOs in training or supervision of general health workers or
psychosocial workers in your district
o Traditional healers: many people with mental health problems seek help from
traditional healers; public health officers should develop positive relations with
these healers and seek cooperation in referral to mental health services.
o Mental health service users and family/carers: facilitate development of service
user and caregiver self-help groups and involve these groups in planning and
implementing mental health programs
 Video: “Breaking the Chains” (10min)
2:15pm-3:00pm
Public Mental Health Intervention Models
 School mental health programs
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o Integrate mental health into school health programs
o Programs for:
 Changing life-skills
 Countering bullying and violence
 Awareness raising about healthy life styles, risks of substance use
 Early detection and intervention for children and adolescents exhibiting
emotional or behavioral problems
o Orientation of school teachers on mental health
Suicide prevention programs such as:
o Increase public, political and media awareness of the magnitude of problem and
the availability of effective prevention strategies
o Increase recognition of risk factors for suicide (mental disorder, chronic pain,
acute emotional stress)
o Restrict access to the means of self-harm and suicide (e.g. guns, pesticides)
o Promote responsible media reporting in relation to cases of suicide.
o Improve health system responses to self-harm and suicide
o Protection of persons at high risk of suicide (women, youth, elderly)
o Optimize psychosocial support from available community resources both for
those who have attempted suicide and for families of people who have
committed suicide
o Decriminalize suicide and suicide attempts
o Monitor suicide in the community (suicide is under-reported due to poor
surveillance system)
Alcohol harm reduction programs, including
o Prohibition of all kinds of direct and indirect advertisement
o Putting in place progressive taxation system
o Limiting sale of alcohol at certain times or in certain locations
o Mobilizing community organizations like mother's groups, youth clubs, etc. in
anti-alcohol campaigns
Workplace mental health programs
o Promote work participation and return-to-work programs for those affected by
mental and psychosocial disorders
o Promote safe and supportive working conditions
o Training on mental health for managers
o Provide stress management courses
o Workplace wellness programs
Improving mental health literacy of the general public
o Educate public about important issues in mental health
o Anti-stigma and anti-discrimination activities in the community using means of
media, rallies, dramas, talk programs, etc.
Mental health promotion
o Promoting spiritual wellbeing: engage and support faith, belief driven, traditional
cultural practices, yogic and meditative practices
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o Strengthen social networks: facilitate or create venues for activities that
promote social network building, such as women’s groups, youth clubs senor
citizen's homes, etc.
o Promote mental health-friendly elements in all policies
3:15pm-4:00pm
Public Mental Health & Disasters
 Disaster: an event which creates a serious disruption of the functioning of a community
involving widespread human, material, economic or environmental losses and impacts,
which exceeds the ability of the affected community to cope using its own resources
 Disasters can be natural (e.g. earthquake) or human-made (e.g. civil conflict)
 Mental health challenges posed by disasters
o Increased rates of mental health problems  greater need for services
 Preexisting mental health problems (e.g. schizophrenia or bipolar
disorders) increase: Break of services with exacerbations, relapses.
 Emergency-induced mood, anxiety, and alcohol and drug use disorders
(e.g. PTSD shown to increase in conflict-affected groups)
 Psychological distress in majority of affected population
 WHO projections of mental disorders in adult populations affected by
emergencies (before vs. after emergency)
 Severe disorder (e.g. psychosis, severe depression): 2-3% vs. 3-4%
 Mild or moderate disorder (e.g. mild or moderate depression and
anxiety disorders): 10% vs. 15-20%
 Normal distress (no disorder): percentage increases in significant
way.
o Weakened mental health infrastructure: disruption & continuity of services
o Difficulties coordinating agencies providing mental health relief services: can
include duplication or poor coverage, over-focus on PTSD, application of nonevidence-based treatments, creation of parallel services; these errors can cause
psychological harm and damage public health infrastructure (e.g. draining health
professionals into parallel structures)
 Guidelines on disaster response
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Mental health effects of Nepal’s civil conflict– findings from previous research
Mental health effects of the 2015 earthquake
o Findings on symptoms and disorders after the disaster based on needs
assessment
o Experience of mental health and psychosocial care response to earthquake:
short-comings and challenges, level of preparedness
Building back better: capitalizing on disasters to reform mental health systems
o In Nepal, several post-disaster initiatives have made efforts to sustainably reform
district-level mental health care systems
o WHO and MoH trained almost all the doctors in highly earthquake-affected
districts (114) on mhGAP Humanitarian Intervention Guide
Discussion activity: Have you noticed any changes in the mental health situation in your
district since the earthquake?
4:05pm-4:50pm
Film: Documentary on Mental Hospital Lagankhel
4:50-5:00pm
Closing
 Select participants who will give summary of day’s learning next morning
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Day 3
9am-9:45am
Recap Day 2 & Project Assignment
 2 participants report what they learned the previous day
Project assignment: The class will be divided into 5 smaller working groups. Each working group
should develop a presentation of about 10-12 minutes (there will be 5 minutes for feedback
and questions after each presentation). Please begin by discussing with your group common
public mental health issues in your districts. Based on this discussion, brainstorm with your
group what strategies you might implement to address these issues. Please prepare to present
two public mental health programs, one focused on prevention of mental health problems and
one focused on mental health promotion. For each program, please address the following
questions:
o What kind of program will you implement?
o What are the program objectives?
o How will you justify the necessity of this program?
o What demographic group does your activity target, and why did you choose this
group?
o How will you plan, manage, organize, and budget for this activity?
9:50am-10:35am
Project Preparation
10:50am-12:25pm
Small Group Presentations
Team leader from each of the five groups will give a presentation before all participants and
resource persons. Each presentation will be followed by five minutes of questions.
1:25pm-2:05pm
Concluding Session
 Feedback and impressions about the training from the participants
 Remarks from the resource persons
 Certificate distribution
 Conclusion by leading resource person/guest
 Group photo session
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Conclusion
Mental health problems are a major contributor to the global burden of disease. There is
compelling evidence that this burden can be substantially reduced through preventative
measures and early intervention and treatment. However, many people living with mental
health problems continue to go without treatment and some additionally suffer human rights
abuses. The United Nations’ SDGs for 2030 call for immediate action to reduce the burden of
untreated mental health problems, reduce suicide, and promote mental health and wellbeing.
International guidelines such as mhGAP and the Global Mental Health Action Plan (2013-2020)
offer a blueprint for achieving these goals, even in low resource contexts. The 66th WHA
resolution calls on member states to develop National Mental Health Action Plans which adapt
and implement these guidelines at the country level.
In Nepal, the government has taken important steps by including mental health as a priority
area in its action plan for preventing and controlling NCDs (2014-2020) by developing
Multisectoral Mental Health Action Plan (2014-2020). These documents embrace a public
mental health approach as the most feasible and cost-effective way to improve the mental
health situation in Nepal. This approach encompasses developing human resources,
establishing mental health policy and legislation, giving care in the community, monitoring of
community mental health, research, integrating mental health into primary care systems,
educating the public, coordinating with other sectors, and involving mental health users and
their families. Given this orientation, the national Mental Health Action Plan designates DPHOs
as the lead agencies on mental health at the district level.
This training aimed to empower public health officers working at DPHOs across the country
with the knowledge, tools, and capacities needed to fulfill the DPHO’s role in mental health
care. Participants have received information on the importance of mental health, priority
mental health problems, resources and constraints in the Nepali context, and public mental
health intervention models and strategies. While a comprehensive national mental health
infrastructure is not yet in place, participants are strongly urged to consider how they can
creatively manage local resources to improve the mental health situation in their districts.
Overall, this training seeks to mobilize Nepal’s public health officers as key actors in achieving
the goals of the national Mental Health Action Plan: to promote mental well-being, prevent
mental disorders, provide care, enhance recovery, promote human rights and reduce the
mortality, morbidity and disability for persons with mental disorders.
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Appendix I: Pre- & Post-Test
Duration of the test: 30 min
Same test is conducted before and after the training.
Question domains:
1. Introduction to Health, Mental Health, and Mental Disorder (18)
2. Importance of Mental Health– Burden & Impacts (1, 9)
3. Overview of Priority Mental Health Problems (2, 6, 19)
4. Mental Health: A Human Rights Perspective (4, 8, 14)
5. State of Mental Health Care in Nepal (17)
6. Gaps and Challenges in Mental Health Care in Nepal (10)
7. Social Determinants of Mental Health in Nepal (7, 13)
8. Nepalese Model of Community Mental Health (5, 11)
9. A Public Health Approach: Role of DPHO (12, 15)
10. Public Mental Health Strategies: Logistics & Partners (3)
11. Public Mental Health Intervention Models (20)
12. Mental Health & Disasters (16)
13. Self-perceived competence (21)
Part A. True or False
1. Depression is one of the leading causes of disability worldwide (t)
2. Mental health problems are uncommon among children and occur only in adults (f)
3. Traditional healers should never be involved in treatment of people with mental illness
(f)
4. Nepal has a National Mental Health Policy and Action Plan (t)
5. Only highly trained mental health specialists can care for people with mental health
problems (f)
6. Suicide is the leading cause of death among women of reproductive age in Nepal (t)
7. Social inequalities may increase the risk of mental health problems (t)
8. People with mental health problems are at reduced risk of human rights abuses (f)
9. Spending in mental health gives good return due to improved economic productivity (t)
10. More than 85% of people with mental health problems in Nepal don’t get treatment (t)
Part B. Multiple Choice
Put  for the correct answer. There is only one correct answer for each question.
11. All of the following play a role in the Nepalese model of community mental health
EXCEPT_________
a. Female community health volunteers
b. Community psychosocial workers
c. Primary care health workers
d. Foreign psychiatric experts
(Ans: d)
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12. The role of the DPHO in mental health care includes ____________
a. Organize training of health and psychosocial care providers
b. Conduct mental health prevention and promotion activities
c. Coordinate with community groups and the social sector
d. All of the above
(Ans: d)
13. Which of the following is an established social determinant of mental health problems?
a. Poverty
b. High caste
c. Buddhist religion
d. Political affiliation
(Ans: a)
14. Which of the following is NOT included in the Sustainable Development Goals?
a. Reducing the burden of untreated mental disorder
b. Promoting mental health and wellbeing
c. Developing more effective psychotropic drugs
d. Reducing premature death due to suicide
(Ans: c)
15. Which of the following is NOT part of the public mental health approach?
a. Integrating mental health into primary care systems
b. Treating all mental health problems in mental hospitals
c. Establishing national policies, programmes and legislation
d. Educating the public about mental health
(Ans: b)
16. Which of the following statements about disasters is true:
a. About 40% of people exposed to disasters develop PTSD
b. All disaster survivors need specialized mental health care
c. The prevalence of severe disorders may increase about 1% after disasters
d. Only man-made disasters such as wars cause mental health problems
(Ans. c)
17. Which of the following statements about mental health resources in Nepal is true:
a. Non-specialized psychosocial care providers play an important role
b. There are ten government mental hospitals in the country
c. Most people with mental health problems receive treatment
d. Psychotropic drugs are not available anywhere in Nepal
(Ans: a)
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18. Which of the following statements about mental illness is true:
a. People with mental illness are responsible for most crimes committed
b. Many effective treatments exist for priority mental health problems
c. Having a mental illness reflects a lack of will power and morality
d. People with mental illnesses cannot lead a normal productive life
(Ans: b)
19. Which disorder is characterized by sadness, loss of interest or pleasure, feelings of guilt
or low self-worth, disturbed sleep or appetite, tiredness, and poor concentration.
a. Anxiety
b. Depression
c. Schizophrenia
d. Dementia
(Ans: b)
20. Which of the following is NOT an effective public mental health intervention:
a. School-based mental health programs
b. Suicide prevention programs
c. Anti-stigma campaigns
d. Confinement of mentally ill people
(Ans: d)
Part C. Short Answer
21. How prepared are you to carry out public mental health activities in your district? What
additional support or training do you need?
22a. (Pre-test only): What is your previous experience with people with mental health
problems?
22b. (Post-test only): Please provide your feedback on this training including how you think
it could be improved.
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Appendix II: Video Content
Included Video Clips:
 “WHO: Introduction to Mental Health” (5.24)
o https://www.youtube.com/watch?v=L8iRjEOH41c
o Section: Day 1 Importance of Mental Health– Burdens and Impacts
 “Mental health situation in Nepal” (13.45): Discusses stigma, lack of awareness, and
human rights abused of mentally ill
o https://www.youtube.com/watch?v=yyelFfZR6Ek
o Section: Day 2 Introduction
 “Democratizing mental health” (9.20): PRIME project as case study of integration of
mental health services into primary care system
o https://www.youtube.com/watch?v=TAAqaNtc9dg
o Section: Day 2– Nepalese Model of Community Mental heatlh
 Breaking the Chains (10.00): How Indonesia successfully integrated service users in
national campaign to end confinement of mentally ill
o Section: Day 2– Public Mental Health Strategies II: Logistics and Partnerships
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