Perspective Chapter: Prevalence and Management of the Panic Disorder in Nepal

Abstract

Although panic attacks are not life-threatening, they can be terrifying and have a substantial impact on your quality of life. Treatment, on the other hand, can be quite effective. Little attention is paid to mental health in Nepal. There is no mental health law and the National Mental Health Policy formulated in 1997 has yet to come into full effect. Unspecified anxiety disorder (15.7%), adjustment disorder (13.9%), and post-traumatic stress disorder were the most frequently diagnosed conditions (8.3%). In 2018, the KCH CAP (OPD) cared for 2477 children, of whom 1529 were men and 948 were women. The most common diagnoses were anxiety disorder (524). Children ranging in age from 6 to 18 years old took part in the study. Nepal has one general hospital dedicated to mental illness and four private mental hospitals. Inpatient mental health care is provided primarily by 19 medical schools, 36 private−public hospitals, and many 27 public hospitals. The counseling situation in Nepal is largely poor. Advanced psychotherapy is provided by 35 clinical psychologists who are licensed practitioners in Nepal. In a 2018 research with 2477 individuals, 524 incidences of anxiety disorders were identified. Supervised counseling and psychotherapy practice is a relatively new concept in Nepal.

1. Introduction

In South Asia, between China and India, the Federal Democratic Republic of Nepal is a landlocked nation. Nepal has a varied topography, with the Tarai, or flat river plain, in the south, hilly areas in the center, and the high Himalayas in the north. The nation, which is divided into seven provinces (Pradesh), is a federal parliamentary republic, with Kathmandu serving as the capital [1].

In the general community, panic disorder is fairly prevalent. It is the anxiety illness that requires the most medical attention and is the most expensive in terms of mental health issues. The Diagnostic and Statistical Manual of Mental Health Disorders (DSM) describes a panic attack as “an abrupt rush of extreme dread or discomfort” that reaches a peak in a matter of minutes. A panic episode is accompanied by four or more of a certain set of physical symptoms. The frequency of panic episodes might range from several times per day to only a few times a year. Attacks happen suddenly, which is a defining characteristic of panic disorder. Often, there is no clear cause of the panic episode. Nepalese aged 16 to 40 suffer from mental health problems, with cases on the rise among children as Nepal conducts its first national mental health survey. Psychiatrists warn that various studies also show that mental health affects people of all ages [2]. Nepal’s population has reached 29,192,480, with a 10.18% rise in the last 10 years [3].

A survey has found that 30% of Nepal’s population suffers from psychiatric problems. Mental health is not well-recognized or taken seriously in Nepal. The government spends less than 1% of its total budget on healthcare in this area. Although precise data are not available on the prevalence of mental disorders in Nepal, small-scale studies have shown the prevalence to be as high as 37.5% in rural communities. In March 1995, the New Communist Party of Nepal (Maoist) (“CPN (Maoist)”) began formulating a plan to launch an armed struggle, the so-called “People’s War,” against the government [3]. Nepal has seen a gradual increase in the incidence of depression, post-traumatic stress disorder, and suicide since the start of the conflict. Health experts estimate the rate of mental health problems in Nepal is as high as 30% [4].

On April 25, Nepal was hit by a magnitude 7.8 earthquake that caused severe damage to 1 of the country’s 75 districts. Two weeks after that, on May 12, another magnitude 7.3 earthquake struck, worsening the humanitarian situation.

Common forms of stress shown in rapid assessments weeks after the Nepal earthquake included fear, anxiety, sadness, anger, sleep disturbances, and increased risk of suicide. Lockdowns, curfews, self-isolation, social distancing, and quarantines brought by the coronavirus disease and COVID-19 pandemic are impacting the overall physical, mental, and social health of Nepalese people. WHO Nepal Office (WCO) assisted the Minister of Health and Population (MoHP) in developing his COVID-19 Mental Health and Psychological Support (MHPSS) intervention framework. World Health Organization (WHO) helped develop the legal and policy framework for the implementation of the National Mental Health Strategy and Plan of Action developed by the Minister of Health and Population (MoHP). This includes required guidelines, standard operating procedures (SoPs), and training manuals [5].

1.1 Institutions

College courses and degrees in modern psychology began their journey to Nepal in the late 20th century at Tribhuvan University. Likewise, their professional training in modern clinical psychology in the form of a Master of Philosophy (M.Phil) in Clinical Psychology began in the late 1990s at the Institute of Medicine, Tribhuvan University (IOM/TU). It, therefore, felt essential to present the growth and development clearly and comprehensively in a clear and comprehensive manner. Specialization and continuing education in the form of fellowships, doctoral and postdoctoral programs, and competency-based training cover various forms of assessment, psychotherapy, neuropsychological approaches, integration with neuroscience, and specific therapeutic modalities, should focus on hyper-specialization in cross-cultural approaches, etc. Two years of M. Phil. in Clinical Psychology can be complemented by a Ph.D. in clinical psychology or the PsyD program. This is possible by setting up an independent clinical psychology department in each institute. More specialists are needed in areas, such as cognitive behavioral therapy, dialectical behavioral therapy, mindfulness-based therapies, couples and marriage therapies, family therapies, sexual therapies, drug and addiction therapies, rehabilitation, and supervision [6].

1.2 Human resources

There are about 147 psychiatrists and 3 child psychiatrists in Nepal. Of these, 110 work in the private sector. It is estimated that there are more than 75 psychiatric nurses and 30 private psychiatrists (Table 1). Almost all specialists are concentrated in large urban areas. There are also an estimated 700 nonprofessional consultants working in the public sector. Specialized training in psychiatry is offered at several institutions, while training in clinical psychology is offered at only one institution. As a result, about 15–20 psychiatrists are added each year, compared to only 2–3 clinical psychologists. However, Nepal does not have training programs for subspecialties, such as substance abuse, child mental health, or mental health for the elderly [7].

		#	Rate per 100,000
Generalist	Doctor	28,477^30	96.0
	Nurse	27,040^31	91.1
	Pharmacist	3761^32	12.7
Specialist	Neurologist	25	0.1
	Psychiatrist	147	0.5
	Clinical psychologist	35	0.12
	Psychiatric Nurse	75
	Lay counselors	~700	2.4

Table 1.

Human resource in mental health.

Despite the high exposure of CAP patients in daily practice, early career psychiatrists (ECPs) say they are not well trained and there is no standardized CAP course for ECPs in Nepal. The desire of the ECP to receive additional training from the CAP is very encouraging and positive [8]. Existing training in psychiatry may not be sufficient to provide meaningful psychotherapy training opportunities for most ECPs in Nepal. It is encouraging that most patients want to continue their psychotherapy training, and there is room for improvement in current psychotherapy training [9].

1.3 Healthcare facilities for mental health

Nepal has one general hospital dedicated to mental illness and four private mental hospitals. Inpatient mental health care is provided in 36 private hospitals and 27 public hospitals. There are also three outpatient services for children and adolescents. Nepal has adopted the mhGAP tools to fit its context, in the form of the Community Mental Health Care Package 2017. Anxiety is one of the common mental disorders included. A set of psychotropic medications, including antipsychotics, antidepressants, anxiolytics, mood stabilizers, and antiepileptics are available at health facilities of all levels across Nepal. Medicines are prescribed by registered medical doctors. However, health assistants employed in primary health care also prescribe after receiving training and following certain government protocols. Counseling on psychosocial is short-duration training. Usually, such training has a time duration of 6 months [10].

1.4 Psychosocial counseling and traditional practice

The historical point of counseling in Nepal has been recorded since the early 1990s. After Nepalese-speaking Bhutanese citizens were deported from Bhutan to Nepal between 1993 and 1996. Places of refuge required not only basic needs but also emotional support. This host country, Nepal, then began to see the importance of counseling after seeing many mental and psychosocial issues [8].

From priests and shamans to doctors with western training, the medical profession has always played a significant role in Nepal. These experts use a stethoscope or a ritual to evaluate the issue. Therapy claims to be able to quiet the mind through rituals or to treat illness with medications. Psychotherapists and counselors are viewed as devoted siblings who wish to hear their patients’ ideas, sentiments, and feelings. To address the crises of torture survivors, the Center for Victims of Torture (CVICT) employs client-centered problem-solving counseling. In addition to focusing on human rights, CVICT also emphasizes client needs, goals, and ideals, as well as empowerment and self-reliance. Most individuals who are familiar with the idea of counseling think that it is all about providing consolation and guidance [11].

Little attention is paid to mental health in Nepal. There is no mental health law and the National Mental Health Policy formulated in 1997 has yet to come into full effect. The counseling situation in Nepal is largely poor. The training courses are usually short and do not involve clinical practice. Training is mostly given by foreign trainers who are new to the cultural environment. Counseling is commonly misunderstood, often resulting in judgmental and uninformed implementation and sometimes wrong practices. The state of counseling is further complicated by the arbitrary application of the word “counselor” to anyone doing social work within a non-governmental organization (NGO) setting. The five-month paraprofessional course begins with a 3-week core training phase, followed by multiple cycles of alternating supervised internships and continuing education courses for increasingly advanced skills and subjects. Working with western-oriented therapeutic assumptions in a non-Western setting requires adjustments to increase cultural relevance [12]. To create qualified counselors, the MA in counseling psychology was introduced in 2017 [13]. Cognitive behavioral therapy is mainly used to address psychological problems by clinical psychologists whereas client-centered counseling is practiced by counselors [14].

A group of gestalt therapists from Europe, formed a Gestalt Psychotherapy Institute in Kathmandu, Nepal. For a group of psychologists and counselors who work with children, refugees, and victims of sexual abuse and torture, the institute would offer psychotherapy and counseling in the area along with a Gestalt psychotherapy training program that adheres to the international standards of the EAGT (European Association for Gestalt Therapy) [15]. The Nepal Youth Foundation (NYF) launched a program called Sandplay Therapy. This has shown to be incredibly beneficial for the youngsters [16].

Supervised counseling and psychotherapy practice is a relatively new concepunderin Nepal. In Nepal, supervised counseling practice is still a novel idea. The majority of it is unsupervised. The study found that students nowadays are handicapped by the overwhelming volume of western study material and the excessively hierarchical supervision they get. The participants understood that the concept of contextualized supervision training had a surprising amount of power [17].

2. Prevalence and management

The planning of the National Mental Health Survey, Nepal started in November 2017 and was carried out in January 2019 and was carried out in all 7 provinces of Nepal from January 2019 to January 2020. The total sample size of the survey was 15,088, including 9200 adults (ages 18 and older) and 5888 youth (ages 13 to 17). The data collection tool consisted of a sociodemographic questionnaire, a translated and adapted Nepalese version of the MINI International Neuropsychiatric Interview (MINI) 7.0.2 for DSM-5, a questionnaire on pathways to obtaining care/help-seeking behavior, and a questionnaire on Barriers to Accessing Care Nursing Assessment (BACE). The overall response rate for adult participation was 96.8% [18].

Worldwide, 10–20% of children and adolescents suffer from mental problems, with 50% of all onsets happening by age 14 and 75% occurring by age 25. A sizeable portion of the population is at risk of developing a mental condition because 40% of Nepal’s population is under the age of 18. Though previously largely disregarded by the health agenda, child and adolescent mental health concerns have lately come to attention in Nepal [19].

Before the pandemic, a number of studies were conducted on the prevalence of mental disorders in the Nepali population. A nationwide cross-sectional study conducted in 2013 among a representative sample of adults in Nepal using the Hospital Anxiety and Depression Scale (HADS) showed age and gender-adjusted point prevalence of anxiety of 16.2% [20].

A systematic review of studies on the mental health impact of the COVID-19 pandemic on the general population in different countries, including Nepal, showed relatively high rates of symptoms of anxiety, depression, post-traumatic stress disorder, mental distress, and stress [16]. Under this pretext, the psychosocial results of the Nepalese population should be examined. However, the effect of COVID-19 on psychosocial well-being in Nepal has now not been thoroughly studied (Table 2).

The outpatient clinic for Child and Adolescent Psychiatry (CAP) headed by Dr. Arun R. Kunwar has been operating at Kanti Children’s Hospital (KCH) in Kathmandu since July 21, 2015. KCH is the first and only government children’s hospital in Nepal to offer specialized services for children and CAP is one of the few specialized services operated in this hospital. In 2018, the KCH CAP (OPD) cared for 2477 children, of whom 1529 were men and 948 were women. The most common diagnoses were anxiety disorder (524). Children ranging in age from 6 to 18 years old took part in the study. Seventy eight of the patients were diagnosed with general anxiety disorder (GAD), and 65 with separation anxiety. Whereas 62 people were diagnosed with social anxiety, 52 with obsessive–compulsive disorder (OCD), 64 with panic disorder, and 60 with physical fear of damage [21].

2.1 Arm conflict and mental health in Nepal

In 2008, 720 people participated in this cross-sectional survey. In the sample, 27.5% of participants reached the criterion for depression, 22.9% for anxiety, and 9.6% for PTSD [22]. Shakya et al. 2011 indicated that many psychiatric disorders had a significant political stressor during armed conflict. The study was conducted with 50 participants. Almost all participants had somatic symptoms followed by anxiety symptoms [23].

2.2 Major earthquake and mental health in Nepal

Little is known regarding what kind of psychological state disaster interventions are effective within the months following earthquakes in areas like the Asian nation. Given the inveterately disaster-prone context, communities should incline the mandatory tools to arrange for future natural hazards and to recover once disasters strike. With this in mind, a three-day integrated psychological state disaster response intervention for earthquake survivors in the Asian nation was designed. The community-based cluster intervention is culturally acceptable, includes header skills and community-building activities, and was tested employing a cluster comparison style. Social cohesion is related to psychological state symptoms, thus higher rates of depression and post traumatic stress disorder (PTSD) are related to lower social cohesion. Participation in a 3-day intervention ends up in a rise in disaster preparedness; a decrease in psychological state symptoms (depression, PTSD); and a rise in social cohesion. Six intervention teams, each with 20 participants, underwent the three-day psychological state integrated disaster readiness intervention at a similar time in every community. Six Nepali clinicians in the United Nations agency were experts in the native languages and were informed with the relevant subcultural team’s junction rectifier of the groups—two in every case. All of them have between 2 and 6 years of expertise in community leadership. Their academic backgrounds ranged from a three-year degree in scientific discipline to a six-month message certificate. Senior members of the analysis team, like the second author, a doctorial level social worker/psychologist, and United Nations agency additionally provided on-the-spot oversight throughout implementation and educated facilitators over the fortnight. The temporary group-based intervention is also scaled up to be used not solely in the Asian nation but also in different nations that usually expertise earthquakes and different natural disasters [24].

Unspecified anxiety disorder (15.7%), adjustment disorder (13.9%), and post-traumatic stress disorder were the most frequently diagnosed conditions (8.3%) shown in Table 3 [19]. Ten papers were identified, all involving 7876 participants. Two studies reported post-traumatic stress symptoms 10.7–51% prevalence of 10.7–51% in earthquake-affected children and adolescents in the Kathmandu district of Nepal. Another study reported that 53.2% of former child soldiers achieved the cut-o score for PTSD. The clinical prevalence of anxiety disorders has been reported as 18.8 to 24.4%, in different clinical samples of children and adolescents [25].

Prevalence of mental disorders among adult participants aged 18 years and above
Disorders	Lifetime (95% CI)	Current (95% CI)
Any mental disorder	10.0 (8.5–11.8)	4.3 (3.5–5.2)
Mood disorders	3.0 (2.5–3.7)	1.4 (1.1–1.8)
Bipolar Affective Disorder	0.2 (0.1–0.5)	0.1 (0.1–0.3)
Major Depressive Disorder (MDD	2.9 (2.3–3.7)	1.0 (0.8–1.4)
Neurotic and Stress related disorders	3.0 (2.5–3.6)
Panic Disorder	0.7 (0.6–0.9)	0.4 (0.3–0.5)
Generalized Anxiety Disorder	0.8 (0.6–1.1)
Phobic Anxiety Disorder	0.2 (0.1–0.4)
Obsessive Compulsive Disorder	0.2 (0.1–0.4)
Post-Traumatic Stress Disorder	0.0 (0.0–0.2)
Dissociative disorder	1.0 (0.7–1.4)
Mental and behavioral problems due to psychoactive substance use
Alcohol use disorder	4.2 (3.6–4.8)
Other substance use disorder	0.2 (0.1–0.3)
Schizophrenia, Schizotypal, and Delusional disorders	0.2 (0.1–0.3)	0.1 (0.1–0.3)
Antisocial personality disorder	0.1
Somatic Symptom Disorder	0.5 (0.3–0.8)

Table 2.

Prevalence of mental disorder among adult participants aged 18 years and above.

ICD 10 Code	ICD 10 Diagnosis	Male		Female		Total
		N	%	N	%	N	%
F43.2	Adjustment Disorder	7	13.5	13	23.2	20	18.52
F41.9	Reaction to severe stress, unspecified	8	15.4	11	19.6	19	17.59
F10.3	Mental and Behavioral Disorder due to use of alcohol	10	19.2	2	3.6	12	11.11
F43.1	Post Traumatic Stress Disorder	4	7.7	5	8.9	9	8.33
F32.1	Depressive episode	6	11.5	3	5.4	9	8.33
F43.0	Acute Stress Reaction	4	7.7	4	7.1	8	7.41
F41.0	Panic Disorder	4	7.7	3	5.4	7	6.48
F20	Schizophrenia	3	5.8	2	3.6	5	4.63
F23.0	Acute and Transient Psychotic Disorder	2	3.8	3	5.4	5	4.63
F41.1	Generalized Anxiety Disorder	1	1.9	4	7.1	5	4.63
F45.1	Undifferentiated Somatoform Disorder	2	3.8	1	1.8	3	2.78
F44.5	Dissociative (conversion) Disorder	0	0.0	2	3.6	2	1.85
G44.2	Tension-Type Headache	0	0.0	2	3.6	2	1.85
F33	Recurrent Depressive Disorder	1	1.9	0	0.0	1	0.93
G43	Migraine Headache	0	0.0	1	1.8	1	0.93
	Total	56	100	52	100	108	100

Table 3.

Disorder diagnosed during the visit to hospital.

2.3 COVID-19 pandemic and mental health in Nepal

Utilizing a multistage proportionate stratified random selection method, a cross-section web-based study design was conducted with 422 Nepalese individuals in the provinces of Bagmati, Gandaki, and Lumbini (Table 4). To measure the severity of depression, stress, and anxiety, the DASS-21 tool was employed. Only 77.5% of whom reported experiencing no stress during lockdown experienced extremely high levels of anxiety [26].

SN	Province	District	Total Population from 18 and above according to census 2011	Sample
1	Province number 3 (Bagmati)	Kathmandu,	1,329,799	143
2	Province 3	Lalitpur	356,023	38
3	Province 3	Chitwan	408,976	44
4	Gandaki Province	Baglunj	171, 841	19
5	Gandaki Province	Syangja	194,696	21
6	Gandaki Province	Kaski	349,893	38
7	Province 5	Rupandehi	580,688	63
8	Province 5	Palpa	171,212	18
9	Province 5	Dang	353,171	38
		Total	3,916,299	422

Table 4.

Sample size of each district.

There has been a negative impact on children and adolescents’ (C&A) access to mental health care throughout Nepal. The mental health of C&A has been impacted by factors, such as school closures, home confinement, lockdowns, transportation issues, uncertainty, disruption of routine, and fear of infection. A suitable strategy to meet these objectives is an online platform. With this in mind, a multi-tiered children and adolescent mental health (CAMH) intervention model was created. It makes use of an online platform to train mental health professionals throughout Nepal, who would then organize sessions for C&A, teachers, parents, and caregivers and connect them to local and remote CAMH services via tele-consultation. With the goal of reaching 40,000 C&A, parents, teachers, and caregivers, this began as a trial program in June 2020 and will run through the end of February 2021. By November 2020, 1415 sessions had been successfully completed using this technique.

Reaching 28,597 people, out of them, 12,026 are parents, teachers, and caregivers from all 7 provinces of Nepal, making up 16,571 child and adolescent (C&A). The multi-tier intervention has been described in this research as a workable approach for resource-constrained settings and low middle-income countries (LMIC) like Nepal. It addresses the COVID-19-related CAMH problems [27].

2.4 Management

Similar to Western ethnopsychology, Nepali ethnopsychology (Figure 1) offers various divisions of the self (see Figure 1). The physical body (Nepali: jiu or saarir), heart-mind (man), brain-mind (dimaag), spirit (saato), soul (atma), and one’s social standing (ijjat) are the primary components. The family (pariwaar), which includes the extended family, and the spiritual realm, particularly connections with one’s ancestors’ deities, are additional significant divisions (kuldevta) (Table 5). The heart-mind and the brain-mind are important subjects in the treatment of mental illness. Memory and emotion are stored in the heart-mind. Psychotherapies including cognitive behavior therapy, interpersonal therapy, and dialectical behavior therapy can all benefit from the use of Nepali ethnopsychology. Any of these ways must have an excellent therapist who simultaneously doubles as an ethnographer [28].

Figure 1.

Nepali ethnopsychological model of the self.

Ethno-psychology Component	Description	Cognitive Behavior Therapy (CBT)	Interpersonal Therapy (IPT)	Dialectical Behavior Therapy (DBT)
Heat-mind (man)	Organ of emotions, memories, and desire	‘Feelings’ in CBT should reference heart-mind processes	Heart-mind processes are examined in the context of social relationships; IPT grief theme relates to the heart-mind	Radical acceptance and change framed in heart-mind and brain-mind conflicts
Brain-mind (dimaag)	Organ of social responsibility and behavioral control	“Thoughts” and “appraisals” in CBT should reference brain-mind processes	Behavioral control through the brain-mind is examined in the context of social relationships	Brain-mind and heart-mind conflicts are reduced; the brain-mind is responsible for regulating “opposite actions” and “response prevention”
Physical body (jiu, saarir)	Physical sense organ, topography of pain	Somatic complaints in CBT may be consequence of heart-mind and brain-mind processes	The connection between physical suffering and relationships is explored through the social world, heart-mind, and physical body	“Opposite actions” and “response prevention” are used to prevent self-injury to the body
Spirit (saato)	Vitality, energy, and immunity to illness	Lost vitality in CBT can be associated with strong emotions in heart-mind (anger, fear)	Loss of vitality can be tied to difficulties in interpersonal relationships with both family and ancestral spirits	Preventing soul loss (saato jaane) is addressed by reducing intensity of emotions in heart-mind
Social status (ijjat)	Personal and family social standing and respect	Social status can be maintained through better insight into thoughts and feelings in CBT	Social status is explored by considering network of relationships; interpersonal deficits related to perceived social status can be challenged	Distress from perceived social status loss (bejjat) is managed through heart-mind emotional acceptance
Family and community relationships	Social support and social burden	The brain-mind processes related to relationships are explored for their effect on heart-mind processes	IPT themes of interpersonal disputes and role transitions examine social relationships	The group therapy component of DBT is used to discuss and model appropriate social relationships

Table 5.

Components of Nepali ethnopsychology in therapy modalities.

The CVICT personnel received training in the Emotional Freedom Technique (EFT), a novel form of therapy, in 1997. This therapy is based on the idea that disturbances in the energy field are what trigger unfavorable feelings. It is a streamlined variation of Thought Field Therapy (TFT) that was created by Gary Craig. It is quite easy to use. Focusing on the issue while lightly touching an acupuncture meridian constitutes this technique. A year later, eye movement desensitization and reprocessing (EMDR) was introduced. A therapy for PTSD that has been empirically demonstrated to be successful (these are post-trauma symptoms, which include nightmares, palpitation, fear, intrusive thoughts, anger, re-experiencing, and bodily pains). These techniques were successfully used for excessive fears, traumatic memories, anxiety, depression, medically unexplained pain, and guilt. There have been cases where one resolved issue leads to another chain of issues, which are treated during consecutive visits [29].

To provide therapeutic recovery to the Bhutanese refugees in Nepal, a community-based group intervention was started. During the Maoist insurgency, group therapy was further utilized and expanded to include war victims in the post-conflict period. Out of several interventions, the International Committee of the Red Cross (ICRC)’s Hateymalo Program, the Problem Management Plus (PM+) group therapy model from the World Health Organization (WHO), Group Interpersonal Therapy (IPT) for teenagers, Dialectical Behavioral Therapy in Nepali (DBT-N) in minority women groups, and Common Thread (sajha-dhago) for women were some of the programs examined [30].

In order to prioritize mental, neurological, and drug use problems, the World Health Organization (WHO) introduced the mental health Gap Action Program (mhGAP) in 2008. The goal of mhGAP is to make it easier for nonspecialized healthcare professionals to deliver evidence-based interventions in basic healthcare settings. In addition, mhGAP promotes expanding access to mental health services by integrating mental health into primary healthcare [31].

2.5 Management in earthquake

In a resource-constrained rural Nepali setting, this research discusses the manualized, cross-cultural adaption of traditional dialectical behavior therapy (DBT) employing an iterative, collaborative, and phasic process approach. It was conducted with one particular subcultural group in rural Nepal, which was identified by its location, its religious preferences, its gender, and its line of work [32].

Tribhuvan University Teaching Hospital [13] promptly developed a 24-hour critical incident crisis management help center, and bed-to-bed psychological assistance was offered in the triage rooms and wards. PFA, trauma therapy, and appropriate psychiatric and nursing care were all delivered immediately by psychiatrists, clinical psychologists, nurses, and residents. The majority of the clients had anxiety disorders, including acute stress reaction (ASR) (44%), acute stress disorder (ASD) (9%), and anxiety disorders not otherwise specified (NOS) (18%). There was counseling for trauma, trauma-focused CBT, and behavioral treatments [33].

2.6 Trauma-focused therapies

A team of local nonspecialist mental health volunteers was trained to identify survivors with PTSD using the PTSD checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. They were trained to deliver either shortened versions of narrative exposure therapy (NET)-revised or group-based control-focused behavioral treatment (CFBT). All adult survivors (aged 18 and above) in Bhaktpur fulfilling the DSM-5 criteria for PTSD were randomly offered either individual NET-R or group CFBT over a period of 2 weeks at the survey base hotel.

Therapists were offered daily on-site supervision by the trainers. All 58 participants who had received a provisional diagnosis of PTSD were randomly split into two groups, with 29 receiving individual NET-R treatments and the other half receiving group CFBT twice, 2 weeks apart. According to the results of the study, CFBT groups based on self-help manuals may be more suitable for rural populations with lower levels of education. Local mental health personnel can be taught brief trauma therapy quickly [34].

2.7 Psychosocial management in COVID-19

With cooperation with the Nepal Association of Clinical Psychologists, WCO also assisted in the national adaptation and translation of the International Federation of the Red Cross Guideline on Remote Psychological First Aid. This publication acted as a manual for adapting the psychosocial support delivery to the particular issues faced by the epidemic. This procedure for delivering PFA remotely was explained to at least 120 counselors [34]. Since the COVID-19 pandemic, it is anticipated that mental problems including depression and anxiety would become more common. Together with the Nepal Association of Clinical Psychologists, the WHO/International Committee of the Red Cross Guideline of Psychological First Aid was also translated and modified for the local environment. More than 40,000 people received psychosocial support in some way; more than 20,000 children and adolescents were offered crucial mental health support; and WHO Country Office for Nepal also hosted regular meetings (mental health subcluster meetings) to coordinate activities among partners. As a result of coordinated efforts, these outcomes were achieved [35].

2.8 The multi-tiered CAMH intervention model

In this intervention model, COVID-19 has been taken as one of the stressors that could adversely affect CAMH. The model incorporates basic psychosocial support for management of stress, tailored more toward COVID-19 related stress, but is not limited to it. This also includes identification and management of CAMH problems locally, and remotely through link with tele-consultation services. The same framework can be used for management of CAMH issues due to other stressors as well. This is a multi-tier model because it includes training of mental health professionals by master trainers through Training of Trainers (TOTs) sessions intervention model, COVID-19 has been taken as one of the stressors that could adversely affect CAMH. The model incorporates basic psychosocial support for management of stress, tailored more toward COVID- 19 related stress, but is not limited to it. This also includes identification and management of CAMH problems locally, and remotely through a link with tele-consultation services. The same framework can be used for management of CAMH issues due to other stressors as well. This is a multi-tier model because it includes training of mental health professionals by master trainers through Training of Trainers (TOTs) sessions (Figure 2). The strategy includes fundamental psychological assistance for stress management, albeit it is not just for COVID-19-related stress. This also involves local and distant management of CAMH issues via connections to teleconsultation services. The same strategy was applied to managing CAMH symptoms brought on by additional stresses. This strategy has several levels (Table 6) since it includes the training of mental health professionals by master trainers through Training of Trainers (TOT) sessions, and the TOT recipients will then lead sessions with C&A, parents, teachers, and other caregivers.

Figure 2.

Flowchart of multi-tiered CAMH intervention phases.

Tiers	Description
One	Children and adolescents in different parts of Nepal
Two	Parents, Teachers, and Caregivers in different parts of Nepal.
Three	Mental health professionals: psychiatrists and psychologists working in different parts of Nepal. They have an MD degree in Psychiatry or Master’s degree in Psychology. Their work includes mental health services primarily targeting adults.
Four	Child and Adolescent Psychiatry team at Kanti Children’s Hospital. This comprises a team of child and adolescent psychiatrists, and clinical psychologists. They have post-MD degrees of specialization in Child and Adolescent Psychiatry and Post-master’s degrees of specialization in clinical psychology, respectively. This team exclusively works in the field of CAMH.

Table 6.

Multi-tiered CAMH intervention.

The incorporation of psychotherapy in psychiatric training was noted by more than two-thirds of ECPs. The majority (67.6%) stated that it required training, while the majority (45%) stated that it only covers theoretical topics. About one-third had expertise in psychotherapy training, mostly in cognitive-behavioral treatment (CBT) (Table 7) [36].

Demographic details and psychotherapy training status of respondents (n = 51)
Demographic details
Gender	Male: 58.8% (n = 30)
Age	Mean 31.3 years (± 3.4)
Job position	Psychiatry trainee: 37.3% (n = 19)
	General adult psychiatrist: 58.8% (n = 30)
	Child psychiatrist: 3.9% (n = 2)
Psychotherapy training in Nepal
Is psychotherapy included in your psychiatry training?	Yes: 72.5% (n = 37)
Mandatory (v. Optional)	Mandatory: 67.6% (n = 25)
Theoretical (v. Practical)	Theoretical: 78.4% (n = 29)

Table 7.

Demographic details and psychotherapy training.

It was considerably less frequent to have experience with interpersonal, family, or other treatments. Table 8, shows that among those who had received psychotherapy training, just half were happy with it. The duration of their psychiatric monitoring, which was stated to be elective by 50% of those who received it, was reportedly less than 50 hours [36].

Respondents’ experiences in psychotherapy training (n = 51)
Have you done any training in psychotherapy?
No, have not trained in psychotherapy	64.7% (n = 33)
Yes, currently training	29.4% (n = 15)
Yes, completed training	5.9% (n = 3)
If Yes, which modality? (n = 18)	Cognitive-behavioral therapy: 94.4% (n = 17)
	Interpersonal therapy: 50% (n = 9)
	Family therapy: 38.9% (n = 7)
	Psychodynamic therapy: 22.2% (n = 4)
	Group therapy: 5.6% (n = 1)
	Motivational enhancement therapy: 5.6% (n = 1)
Have you undergone personal psychotherapy?	Yes: 3.9% (n = 2)
Psychotherapy supervision
Access to supervision	66.6% (n = 12)
Mandatory (v. Optional)	Optional: 58.3% (n = 7)
Format of supervision (n = 12)	Individual: 41.6% (n = 5)
	Group: 25% (n = 3)
	Mixed: 33.3% (n = 4)
Duration of supervision (n = 12)	<50 h: 58.3% (n = 7)
	50–100 h: 16.7% (n = 2)
	>100 h: 25% (n = 3)
Satisfaction with psychotherapy training (n = 18)
	Dissatisfied: 22.2% (n = 4)
	Satisfied: 50% (n = 9)
	Neither satisfied nor dissatisfied: 27.8% (n = 5)

Table 8.

Respondent’s experience in psychotherapy.

3. Conclusions

Since the war, a significant earthquake, and the COVID-19 epidemic, there have been increased reports of mental health problems. Panic disorder is one of the most prevalent mental health conditions. In addition to DSM-5, ICD-10 is the diagnostic code most frequently employed by practitioners. Panic disorder is one of the conditions that is frequently identified. Patients with panic disorder get both medication treatment and psychotherapy, as well as deep breathing exercises and progressive muscular relaxation. Cognitive behavior therapy is the therapy that is used the most frequently. A research report generally does not contain case studies of recognized panic disorder. Although there is a specific study on other problems, such as substance use disorders, schizophrenia, mood disorders, anxiety, and depression. On the subject of panic disorder particularly, the little study is done. In the country’s capital, there is a greater concentration of mental health services. Access to the service might be challenging for people who live in rural locations. As a result, there is a great probability that they will not receive proper care in addition to the traditional healer. Small-scale surveys and one nationwide survey both demonstrate the prevalence of panic disorder. However, there is relatively little research done on counseling and psychotherapy. The need for psychotherapeutic management is growing at the moment, but there is a lack of public awareness. Long-term treatment built on academic training should be implemented as part of national health policy. More resources and attention should be devoted to mental health in Nepal than are currently being done.

Acknowledgments

The author would like to thank Dr. Arun Raj Kunwar MD, Head of Child and Adolescent Psychiatry Mental Health (CAPMH) Unit, Kanti Children’s Hospital, Dr. Jasmin Ma MD, Project Manager, Child and Adolescent Psychiatry Mental Health (CAPMH) Unit, Kanti Children’s Hospital, Child Workers in Nepal Concerned Centre (CWIN), Dr. Binod Dangal MD, Pasupati Chaulagain Memorial Hospital, and the team of Nepalese Association of Clinical Psychology.

Conflict of interest

“The authors declare no conflict of interest.”

Appendices and nomenclature

#

Number

ASD

Acute Stress Disorder

ASR

Acute Stress Reaction

BACE

Barriers to Accessing Care Nursing Assessment

CPN

Communist Party of Nepal

COVID-19

Corona Virus Disease-2019

CAP

Child and Adolescent Psychiatry

C&A

Child and Adolescent

CFBT

Control-Focused Behavioral Treatment

CVICT

Centre for Victims of Torture

CWIN

Child Workers in Nepal Concerned Centre

DBT

Dialectical Behavior Therapy

DBT-N

Dialectical Behavioral Therapy in Nepali

DSM-5

Diagnostic and Statistical Manual of Mental Health Disorders-5

EAGT

European Association for Gestalt Therapy

ECPs

Early Career Psychiatrists

EFT

Emotional Freedom Technique

EMDR

Eye Movement Desensitization and Reprocessing

GAD

General Anxiety Disorder

HADS

(Hospital Anxiety and Depression Scale

ICD

International Classification of Diseases

ICRC

International Committee of the Red Cross

IOM/TU

Institute of Medicine, Tribhuvan University

IPT

Interpersonal Therapy

KCH

Kanti Children’s Hospital

LMIC

Low Middle Income Countries

MA

Master of Arts

MoHP

Minister of Health and Population

MINI

International Neuropsychiatric Interview

M. Phil.

Master of Philosophy

mhGAP

Mental Health Gap Action Programme

NET

Narrative Exposure Therapy

NYF

Nepal Youth Foundation

NGO

Non-Governmental Organization

NOS

Not otherwise specified

OCD

Obsessive Compulsive Disorder

OPD

Outpatient Department

PM+

Problem Management Plus

PhD

Doctor of Philosophy

PsyD

Doctor of Psychology degree

MHPSS

Mental Health and Psychological Support

PTSD

Post Traumatic Stress Disorder

PTSD checklist

Post Traumatic Stress Disorder Checklist

SoPs

Standard Operating Procedures

TFT

Thought Field Therapy

TOTs

Training of Trainers

WCO

WHO Nepal Office

WHO

World Health Organization