<figure><img width="1500" height="1010" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101116/636b704d9c7e80680e06006fjpeg.jpg" alt=""/><figcaption>Photo: MONIKA DEUPALA</figcaption></figure>Nepal’s public health system has no mechanism for recording suicides, and the only statistics about suicides can be found in police records. This data shows that about 5,000 Nepalis kill themselves every year. But since only police records are counted and attempted suicides are not reported, the official data gives no sense of the incidence of people trying to take their own lives. Based on police data and projections, the World Health Organisation put Nepal as the country with the 7th highest suicide rate in the world (24.9 per 100,000). Public health experts say that suicide is just the symptom, and that the real disease is poor mental health.Read also: <a href="https://www.nepalitimes.com/here-now/suicide-by-pesticide-in-nepal/" target="_blank" rel="noopener">Suicide by pesticide in Nepal</a>, Sonia AwaleMost people who commit suicide suffer from depression and other mental illnesses like schizophrenia and substance abuse disorders. The Nepal Health Research Council (NHRC) is for the first time conducting a nationwide survey of mental health by year-end, and already the picture is not looking good.Do not shy away from seeking help. If you, or anyone you know, would like to speak to a trained mental health professional, please contact:TUTH Suicide Hotline: 9840021600Transcultural Psychosocial Organization-Nepal Crisis Hotline: 1660 0102005Mental Health Helpline Nepal: 1660 0133666“From our pilot survey, we found depression in 3.4% of people, and suicidal tendencies in one out of every ten Nepalis,” says Kriti Adhikari of NHRC.  Most of these people cannot access the counselling and treatment they need since Nepal has only 0.13 psychiatrists per 100,000 people, and most of them are concentrated in urban areas. Nepal Police is the only entity that deals with suicide, and it is more concerned about the criminality of the act than about mental health.“Nepal’s law classifies suicide and abetting suicide as crimes, so our priority is figuring out the criminal element of the cases,” explains police spokesperson Shailesh Thapa Chhetri. “There is no punishment for suicide because the person is already dead. But we investigate to find out if the death was a murder or a suicide.”Read also: <a href="https://www.nepalitimes.com/latest/suicide-watch/" target="_blank" rel="noopener">Suicide watch</a><a href="https://archive.nepalitimes.com/article/nation/down-and-out,3158">Down and Out</a>, Smriti Basnet <figure><img width="1500" height="947" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101116/636b704f9c7e80680e060070jpeg.jpg" alt=""><figcaption> </figcaption></figure>The fact that Nepal Police personnel are not trained in mental health, and that the health system does not record suicides or suicide attempts means that there is no entry for suicide in the Health Information Management System, the database of all patients at government health facilities. This keeps suicides hidden. “The police data on suicide understates the problem of mental health in Nepal,” says Ravi Shakya, a physician at Patan Hospital, which has a mental health department. “We know more men die from suicide than women and they tend to use more violent means. But in fact, many more women attempt suicide and fewer of them succeed. They may come to hospital, recover, and go back home, but that does not mean their mental illness is over.”Except at Patan Hospital, victims of attempted suicides receive no mental health counselling after their physical health improves. But last year the Ministry of Health and Population appointed a focal person for mental health for the first time. This focal person, Phanindra Baral, acknowledges that Nepal has not done enough to address mental health and suicide prevention.Read also: <a href="https://archive.nepalitimes.com/page/suicide-in-nepal">End pain, not lives</a>, Anjana Rajbhandary“There are not enough psychiatrists in Nepal to serve the whole country. So for now, we are training the current health staff in basic mental health issues and counseling,” says Baral. “We are taking the program to 41 districts this year, and hope to serve all 77 districts in the next two years.”For the first time, the Ministry has included mental health as a priority in its proposal to the National Planning Commission, hoping to see that reflected in the next five year plan. But till that happens, there are other things to be done.“Mental health still has a stigma and people are not willing to acknowledge it or seek help. The first step is to raise awareness of mental health and suicide,” says Uden Maharjan, public health researcher and co-author of a paper on suicides in Nepal. “We need suicide helplines and people should be made aware of how to access them so they can open up.”  Read also: <a href="http://archive.nepalitimes.com/news.php?id=16792#.XhbkgFUzbIU">Self-destruct</a>, Indu Nepal <a href="https://www.nepalitimes.com/here-now/dead-end-of-the-korean-dream/">Dead end of the Korean Dream</a>, Ki Mindo in Seoul <h2>A note on suicide notes</h2> With the spread of social media, police have to contend with suicide notes not just on paper but also on the Internet platforms. But the real challenge of dealing with suicide note is still the same: the mental health. Should the declaration of a dead person be believed? And if the dying declaration blames someone else for that death, how credible is the allegation?Ravi Shakya, a physician at Patan Hospital says that dying declarations are usually held to be credible evidence. “When someone declares that they are want to die and proceed to kill themselves, we have every reason to take such a note seriously,” says Shakya. “However, if they blame another person, we cannot assume guilt based on the allegation. We have to take into consideration that the person who committed suicide could have been mentally ill.”The police also take such suicide notes seriously, but prioritise criminal investigation over mental health. “A suicide note is evidence, so we treat it with utmost care. We analyse the handwriting to make sure it matches the dead person’s. If the dead person blames other people, we consider them under suspicion until they are proven innocent,” says Shailesh Thapa of Nepal Police. The police do not necessarily question the sanity of the person who wrote the note, therefore sidelining the mental health aspect of the suicide.Read also: <a href="https://www.nepalitimes.com/here-now/dead-end-of-the-korean-dream/" target="_blank" rel="noopener">Dead end of the Korean Dream</a>, Ki Mindo in Seoul

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Nepal’s suicide rate vastly underestimated

<figure><img width="1400" height="932" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110714114/636902db9c7e80680e037c8bjpeg.jpg" alt=""/><figcaption>Source: The Lancet</figcaption></figure>The debilitating effects of mental health diseases and the <a href="http://archive.nepalitimes.com/news.php?id=14138#.W2MFj9Uza70" target="_blank" rel="noopener">social stigma associated with them</a> are not limited to patients: the lives of family members also change irrevocably. Family support can also be an important source of strength and even help in the healing process, say psychiatrists, patients and their relatives.Reshma Magar from Sindhuli, brought her 35-year-old son to a mental health clinic in Kathmandu after he displayed symptoms like severe headaches, mouth fizzing, and haphazard running around. As a mother, she was constantly worried he might hurt himself.“We have the Sun Kosi River nearby and I would think: what if he jumped?” says Magar, who has to tie him up in the hospital bed to contain his violent behavior. “I would be crying and the nurses here would console me.”Read also: <a href="https://www.nepalitimes.com/?p=10647&amp;preview=true" target="_blank" rel="noopener">Raising children can be therapy</a>, Ketan DulalNabina and Samira Pradhan shared similar hardships. Their brother, 40, started showing erratic behaviour after his wife left him, taking their daughter with her. He throws things around, does not eat, and their 71—year-old mother has to look after him.“It is very hard,” Nabina says, “mother herself has health issues and because of our brother’s state, violence in the home remains a constant danger.”Sufferers of psychotic mental illnesses are generally unaware they have a problem. In <a href="http://archive.nepalitimes.com/article/nation/stigma-and-silence-mental-health-nepal,3486" target="_blank" rel="noopener">schizophrenia</a>, a severe psychotic disease, patients have a distorted sense of reality − hallucinations, extreme paranoia, hearing voices − that their mind infers as truth. They resist help, and family members have a difficult job coaxing them to seek and continue medical treatment.Beyond this, the emotional trauma of having a suffering relative is a constant feature of life for the Magar and Pradhan families, which makes each day frightening and unpredictable.Read also: <a href="https://www.nepalitimes.com/?p=10641&amp;preview=true" target="_blank" rel="noopener">Addicted to the joystick</a> , Suprasanna AryalResearch has shown that patients suffering from psychosis have various structural and functional abnormalities in the brain. Schizophrenia patients have dysfunctions in their neurotransmitter systems, metabolic pathways and certain structures in the brain regulating motor activity.Traditionally Nepali society, which did not have coping mechanisms, regarded mental disorder as a curse, and there is strong social stigma and ostracisation of both the patients and their families. Derogatory labels for <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/overcoming-depression,2164" target="_blank" rel="noopener">‘crazy’ people like ‘dimag khuskeko’ or ‘pagal’</a> are still widely used.However, now that science has shown that the causes are mostly chemical imbalances, there is treatment says Basudev Karki of Lagankhel Mental Hospital: “Medicine now has treatment for mental diseases, just like for physical ailments. Problems of the mind also need medical care and treatment and there is nothing wrong in that. Instilling this understanding will help address stigma for patients.”Read also: <a href="https://www.nepalitimes.com/?p=10601&amp;preview=true" target="_blank" rel="noopener">Ashna comes out of black</a>, Sewa Bhattarai <img width="670" height="585" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110714114/636902de9c7e80680e037c8cjpeg.jpg" alt="">However, Karki cautions that medical interventions alone sometimes do not suffice because the triggers may be a combination of biological, psychological and social factors. For example, there was a <a href="http://archive.nepalitimes.com/article/editorial/the-republic-of-insomnia,3311" target="_blank" rel="noopener">surge in mental disorders in Nepali society</a> during <a href="http://archive.nepalitimes.com/article/nation/psychological-scars-of-maoist-conflict-on-young-survivors-take-longer-to-heal,1519" target="_blank" rel="noopener">the conflict</a> and after <a href="https://www.nepalitimes.com/here-now/its-all-in-the-mind/" target="_blank" rel="noopener">the earthquake</a> and Blockade. Out-migration and family separation pushes people into another class of mental illness, like neuroses, such as <a href="http://archive.nepalitimes.com/regular-columns/all-in-mind/the-silent-scream-depression-is-common-but-only-few-get-treatment,588" target="_blank" rel="noopener">depression</a> and anxieties in which, unlike psychosis, the patients preserve a sense of reality.Following hospital treatment it is up to family to provide psychological support for patients, to think positively and maintain a healthy lifestyle. They must protect patients from extreme stress due to social factors, such as unemployment or financial trouble.Muna Tamang shows extraordinary determination this week as she sits beside the hospital bed of her 24-year-old daughter who is suffering from psychosis. “As long as she can live and heal, I have decided that we will do anything for her treatment, even if we have to take loans,” Tamang told us.Read also: <a href="https://www.nepalitimes.com/here-now/its-all-in-the-mind/" target="_blank" rel="noopener">It's all in the mind</a>, Sonia AwaleNepal’s mental health facilities are mostly based in cities, but even here there aren’t enough trained specialists to deal with what is a national mental health epidemic. Up to one-third of Nepal’s population suffers from some form of mental illness, according to one study. (See chart)One group, The Transcultural Psychosocial Organistaiton (TPO) is working to remedy the urban-rural mental health gap, by training doctors and health workers at the local level with Female Community Health Workers.“We do not just want to make these services available, but to also ensure people reach out to them, and refer patients to seek help in facilities,” says Kamal Gautam at the TPO.Such efforts have helped remove stigma, and empowered patients and families to receive treatment and care. But Nepal still has a long way to go. With greater state investment, access to mental health services and proper therapy, family members can be even more involved in helping patients and reducing their stigma.Some names have been changed.

All in the family

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110714114/636902e69c7e80680e037c8fjpeg.jpg" alt="" width="1400" height="1050"/><figcaption>Kunda Dixit</figcaption></figure>When my daughter was born I was not present during the delivery. I could not hold her like most parents after their newborn is brought into this world.Here I was in Canada, and she was born in Nepal. At five months, she arrived at Charlottetown airport. I did not hug her first, because her mother who had warned me on Skype: ‘Don’t suddenly hug your daughter, she gets spooked easily.’She is a beautiful baby and I can see myself spending a lot of time with her as she grows up, as I dream about what kind of person I want her to be.Why become a parent? The evolutionary reason for it is that you want to leave your genes after you pass on. But that idea is wrong. Parenthood, as Andrew Solomon says in his book Far <a href="https://www.amazon.com/Far-Tree-Parents-Children-Identity-ebook/dp/B007EDOLJ2" target="_blank" rel="noopener">From the Tree</a> , is an act of production rather than reproduction. Seeing ourselves in our progeny is a profound mistake.Parenting is anything but normal. What you are doing in becoming a parent is sacrificing your life to a being, while not knowing how they will turn out. It is a fulltime job for which there are no wages.In <a href="https://www.amazon.com/Gardener-Carpenter-Development-Relationship-Children/dp/1536617830" target="_blank" rel="noopener">The Gardener and Carpenter</a>, psychologist Allison Gopnik has problems with the current model of parenting. Parents, instead of thinking themselves as guardians of their children and trying to mould them into what they want them to be, should instead let them flourish as they are, she says.To build such a relationship with children is the key to becoming a parent. It is especially important for parents with <a href="http://archive.nepalitimes.com/article/nation/stigma-and-silence-mental-health-nepal,3486" target="_blank" rel="noopener">mental illness, like me</a>. The stereotypical view is that parents with mental illness are not good at their job. Admittedly that has been supported by some studies, which show that parenting can indeed lead to more stress for fathers and mothers with mental illness.Read also: <a href="https://www.nepalitimes.com/?p=10636&amp;preview=true" target="_blank" rel="noopener">All in the family</a>, PRAKRITI KANDELHowever, there have also been several studies to show that raising children can actually bring about short and long-term change in the hormones in the parents' brains. The attachment between mother and child, for instance, is stimulated by the production of the hormone oxytocin in the brain. Oxytocin levels in fathers also seems to increase following the birth of a child and during interactions with infants.Similarly, testosterone in the brain of a father decreases after a child is born and following interaction with children, although it may help in protective response, for example, when the child is threatened by a predator.Parenting can also be a therapeutic tool for patients with mental diseases like <a href="https://en.wikipedia.org/wiki/" target="_blank" rel="noopener">schizophrenia</a>, who are under antipsychotic medications that block the receptors of dopamine. However, although antipsychotics can treat symptoms of schizophrenia (like hallucinations and delusions) it is ineffective in treating other symptoms like lack of motivation.Oxytocin, on the other hand, is involved in the process of attachment. The hormone can be used as a therapeutic agent to reduce some symptoms of schizophrenia. And since it is produced also in fathers and mothers when they interact with their children, parenting could be an antidote to the disorder.The most important thing for parents with mental disease like schizophrenia is not to be too anxious about how their children are going to turn out as they grow up, but look to develop lasting relationships with them.Parenting can be stressful, but is a blessing. Developing good parenting skills to build good relationships with our children (without trying to mould them) can be an effective tool for handling <a href="http://archive.nepalitimes.com/article/editorial/the-republic-of-insomnia,3311" target="_blank" rel="noopener">mental disease</a>.I have schizophrenia, and one of the things that I do to reduce relapse is interact with my daughter as much as possible and also build a positive approach to my parenting job.Ketan Dulal is a PhD candidate at the University of Prince Edward Island in Canada.Read also: <a href="http://archive.nepalitimes.com/article/nation/stigma-and-silence-mental-health-nepal,3486" target="_blank" rel="noopener">Stigma and silence</a>, Ketan Dulal<a href="https://www.nepalitimes.com/here-now/its-all-in-the-mind/" target="_blank" rel="noopener">It's all in the mind</a>, Sonia Awale<a href="http://archive.nepalitimes.com/article/editorial/the-republic-of-insomnia,3311" target="_blank" rel="noopener">The republic of insomnia</a>, Editorial

Raising children can be therapy

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