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Posted by Dr. Arunima Rajbhandry

Bayalpata Hospital outpatient department was crowded with patients, all lined up eagerly to be seen by a clinician. I was done seeing my first few and rang the bell to call for the next patient. A thin, nervous looking middle-aged woman walked in, along with her teenage daughter.

“I have a headache,” she said looking down, avoiding my eyes.

“Okay, tell me more about it,” I said as I lowered my head to get a good look at her face.

She paused for a few seconds, then, hesitantly uttered, “I see normal people as if they have long teeth and long bushy hair, like a demon.”

It took me a few seconds to comprehend what I had just heard. “Normal people walking down the street…they appear like demons. And I am afraid I might attack them like I did before.  I am scared I might go crazy again like I did before,” she blurted out in a single breath.

“I don’t want to go crazy again because it hurts me a lot. Last time, when I went crazy, people tied both my hands. Then they hit me. They hit me so hard on my head that my head still hurts. Then they locked me up in a dark room for days. Please give me some medicines so that I don’t go crazy and I don’t get beaten up again,” she said.

Patients wait outside of Bayalpata’s outpatient department to be seen. On an average day Bayalpata Hospital sees between 100 and 150 outpatients.

“We took her to Nepalgunj.” The teenage daughter added “They gave her these medications which helped her a lot. Please give my mother the same medicines.” She handed me a packet of Benhexol (an anticholinergic agent) tablets.

“Were any other medications given?” I asked. She was adamant that it was the only medication used.

“We cannot go back to our village because the people will kill my mother. Three years ago when she went crazy, they tied both her hands and pushed her down from the top of the hill into the jungle to die.  My younger brother and I could not let her die. So, we went into the jungle to save our mother. After that incident, we moved to Sanfe.  If my mother loses her mind again, then the community will not let us stay in Sanfe either. Please give my mother some medication,” she added.

I asked her to describe what her mother was like in the previous episode. She told me that three years ago, her mother was completely crazy. She would attack people, tear her own clothes and eat dirt. She and her brother had a hard time keeping her covered. She used to wander around and they had to search for her all over the place. She also said that her mother used to talk about some noise like drums or music being played when nothing was actually playing. But, the patient herself denied hearing any clear voice or seeing any image. She never felt like she was being commanded to do things. She was never exuberant, talkative or over ambitious. And she never had crying spells, loss of sleep or a depressed mood.

“How do you feel now?” I asked.

She had tears in her eyes as she said, “I am afraid I will go crazy and get beaten up again. I am scared to go to the market. I have not started hearing anything strange or doing anything strange but I have started seeing normal people as demons again.”

I asked the daughter if her mother ever talked to herself or said she saw demons when nobody was present. She said she only imagined real people as demons.

I referred her to Uday, the Health Assistant trained in CMC (Community Mental Health Counseling) who listened to her, counseled her and prescribed her Chlorpromazine, Amytriptyline and Benzhexol with plans to follow up after a week.

Her agonizing story has been haunting me. The fact that she was deprived of treatment for a long time, poorly treated, physically abused and almost killed for having a disease is absolutely tragic.

This case is only one of many that I have encountered at Bayalpata Hospital.  I have been surprised by the complete ignorance about mental health in the community.  It is interesting to note that mental illness is not seen as a disease but rather referred to by various terms like “bhut chadkheko” (possessed by a ghost) and “deuta lageko” (possessed by a god).

The one encouraging thing is that the younger generation–this current patient’s daughter, another patient’s grandson—are recognizing mental illness and seeking medical care for their relatives at Bayalpata.  They are not willing to accept traditional beliefs widely held in the community.  Nevertheless, we need to do more to increase awareness of mental illness here in Achham.

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Dr. Arunima Rajbhandary completed her MBBS at BPKIHS, Nepal. She is currently a volunteer for Nyaya Health.

2 Responses to “Mental illness under-diagnosed and untreated”

  1. Julia says:

    Arunima, thank you for sharing this story. It will haunt me now as well. Mental health is so neglected, and I’m thankful that you and Nyaya Health are there to help people like the woman in this story. What a brave daughter she has. I, too, believe that awareness/education and stigma-reduction are two ways we can all help tackle this issue around the world.

    It is indeed interesting how misunderstood mental illness is in many places. I experienced something along the same lines when I spent three years teaching in rural Ecuador. I remember waking up one day and realizing that one of my students who had been struggling was probably dyslexic. When I went to speak to the school’s administrators to learn what we could do for students with learning disabilities, I was basically told that there was no such thing as a learning disability and that it all boiled down to laziness and stupidity. I spent a lot of time thinking about the situation and came away wondering if people go into denial or create alternative explanations when they simply don’t have the means for addressing the real issue at hand. With no special programs to address anything like dyslexia or ADD much less something like autism, I don’t think they saw the value in “diagnosing.” And part of me believes that they were ashamed to have me as a North American outsider telling them that one of their students might have dyslexia.

    All the best to you and your patients in Achham!

  2. Dr Prabhakar Pokhrel says:

    Hi, i am currently doing my MD psychiatry in PGIMER Chandigarh. Its so disappointing to see how people are deprived of basic health facilities and level of awareness regarding mental illness. Coming to any sort of medical health is the last resort after all other stuffs are complete, including faith healers, home made methods(includes physical abuse, restraining, locking in the room and many more). it is very sad on the part of the index case to be tied and thrown in the jungle in response to her illness and certainly love and strength in the part of the children to save their mother. Sadly this is not a rare event. Good job on your part and the team to reach to these people and help them out. I think lot of awareness regarding mental illness has to be the first approach and side by side access to atleast basic health services( including good referral system) will add hope and trust to the awareness of the illness. Though its easy said than done but we don’t have other option, do we? so all the best for the efforts and thanks for sharing your experience.
    Dr Prabhakar pokhrel

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