Assessment of mental health and psychosocial support needs and resources among earthquake-affected communities in Nepal

Executive Summary:
This report details the results of a mental health and psychosocial support resource and needs assessment in Kathmandu, Gorkha, and Sindhupalchowk districts, three of the most affected areas in Nepal following the earthquakes of April 25 and May 12, 2015. The assessment was conducted in August-September 2015 by the Transcultural Psychosocial Organization Nepal (TPO Nepal) and supported by International Medical Corps (IMC) whose emergency response operations started directly after the earthquakes.

The needs and resource assessment was based on Inter-Agency Standing Committee (IASC Nepali version) Guidelines and good practice principles for assessments outlined by the World Health Organization (WHO) and United Nations High Commissioner for Refugees (UNHCR) (2012). The assessment used a mixed methods design with both qualitative (freelisting activity, in-depth interviews, focus groups) and quantitative (survey) approaches.

Key findings from qualitative assessment results:
• Community members were deeply impacted in many ways by the earthquakes: participants most frequently reported experiencing their own homes collapsing; the deaths of family and loved ones; witnessing destruction of neighbors’ homes, schools, and hospitals; and seeing dead bodies.
• Participants expressed that mental health and psychosocial problems were common in their communities following the earthquakes, particularly fears, such as feeling frightened that an earthquake would occur again. Behavioral (e.g., increased anger/aggression), cognitive (e.g., forgetfulness), sleep (e.g., lack of sleep as well as too much sleep), somatic (e.g., numbness/tingling in limbs), emotional (e.g. sadness, hopelessness), and alcohol use problems were mentioned as significant problems.

Key quantitative assessment results:
• High overall reporting of depression (34.2%), anxiety (33.8%), and alcohol use problems (20.4%)
• Lower reporting of post-traumatic stress symptoms (5.2%)
• Suicidal ideation in the overall sample was 10.9% in the four months following the earthquake
• Average functional impairment scores were overall very low (2.83, possible range 0-27) suggesting low levels of dysfunction. Scores were slightly higher in Sindhupalchowk (5.12) compared to Gorkha (2.14) and Kathmandu (2.31). Although functional impairment scores were low, there were strong associations between impaired functioning (high scores) and risk for reporting symptoms of mental health problems (depression, anxiety, PTSD, and alcohol use).
• Populations at particularly increased risk for mental health and psychosocial problems were females, older people, Dalit and Janjati caste, and communities in Sindhupalchowk district.

Key sources of support and mental health services
• Family, neighbors and community members, and religious leaders were the most commonly used sources for managing mental health and psychosocial problems.
• Negative coping strategies were considered highly prevalent by our participants, including excessive alcohol use, smoking, and gambling.
• Support for mental health problems were provided through two mechanisms: by traditional healers and by doctors, counselors, psychiatrist, or other mental health professional in a hospital or health post setting. Most often, community members sought care from a traditional healer and proceed to a hospital or health post only if the
traditional methods were considered unsuccessful. Participants believed that both methods could be helpful in managing mental health and psychosocial problems but that the services provided in health posts or hospitals were insufficient for the demand by community members and that services were in some cases inaccessible due to shortage of trained professionals, destruction of clinics by the earthquakes, or large distance to the clinics.

Types of services requested by participants
• The most commonly recommended service by participants was improved access to basic needs: shelter, food, clean water, toilets, and improved sanitation.
• They also recommended increased training for current psychosocial workers and non-specialist primary care providers, the establishment of permanent mental health centers within hospitals and health posts, and trained and qualified mental health professionals to staff those centers.
• Psycho-education and earthquake awareness education were also recommended.

Overall, the needs assessment has identified that a wide range of mental health and psychosocial problems is having a significant impact on a substantial proportion of the populations affected by the earthquakes. The report recommends a multifaceted approach to addressing the needs of the affected populations following the IASC MHPSS Guidelines pyramid structure.:
• Basic services and security (e.g., advocating to local leaders for increased and dignified access to basic needs)
• Community and family supports (e.g., promotion of communal healing through utilization of existing social supports; suicide prevention programs, mental health awareness and stigma reduction)
• Focused, non-specialized supports (e.g., promoting coordination of care between traditional healers and hospital/health post/mobile mental health clinic staff and increased engagement with traditional healers, provision of psycho-education;)
• Specialized services for those with both mental health problems and functional impairment and focus on populations at high risk (e.g., targeting those with suicidal ideation and those with both mental health problems and impaired functioning, which may indicate greater severity of disorder); integration of mental health services with alcohol abuse services).