Nuwakot, Nepal - Ever since the earthquake, Mithu Pyakurel has suffered flashbacks of the shaking and has trouble recognising her relatives.
Lying listless on a hospital bed in a car park turned emergency ward, 70-year-old Pyakurel tries to jump up and flee whenever the anti-anxiety medicine she's taking wears off.
"[She] starts getting scared and starts shouting that the earthquake again has come," said Dr Arati KC at the rural makeshift hospital in Nepal's Nuwakot district, where she and her colleagues relocated after their hospital was damaged in the quake.
"She's really very troubled."
Pyakurel's hyper-anxious state is exacerbated by the lingering aftershocks, said one doctor.
Doctors treating victims of the devastating April 25 quake that killed more than 7,500 people are seeing cases of deep grief, anxiety, and depression.
Mental health experts say the most vulnerable to developing prolonged conditions are children, the disabled, and the elderly.
The World Health Organization and the United Nations High Commissioner for Refugees have issued a new guide for identifying and managing mental health needs in humanitarian disasters. WHO estimates that five to 10 percent of people in humanitarian emergencies suffer from mental health problems afterwards.
After the earthquake, the car park hospital in Nuwakot - a district where 909 people died, according to government figures released Wednesday - was flooded with patients.
|America Nepal Medical Foundation staff unsuccessfully attempt to revive Pasang Lama [Annette Ekin/Al Jazeera]
On Monday, less than 30 beds with patients remained, but the distress from those who were there was palpable.
A local woman who had collapsed was brought to the hospital. She lay a few beds away from Pyakurel and couldn't be revived. The woman, 85-year-old Pasang Lama, wasn't injured in the earthquake, but had severe stress after her daughter-in-law and grandson died, said Dr KC.
A few days earlier, another woman reportedly hanged herself after losing her daughter. "These are just the cases that are the tip of the iceberg," KC said.
Food, water, and shelter remain urgent needs for Nepal's earthquake victims as concerns about disease outbreaks mount with the approaching monsoon season.
But as surgical cases decrease and foreign medical units draw closer to pulling out of the country, quake victims and their families face a long battle ahead coping with emotional trauma.
Staff at the Nuwakot hospital have been working with a 62-member medical team from Bhutan who've set up a field hospital.
At the Bhutanese camp, a one-and-a-half-year-old girl with scratches on her face cried inconsolably in her grandmother's arms.
On the day of the 7.9-magnitude temblor, her mother had taken her out to the forest to collect firewood. A boulder from a landslide crushed the woman, who was nine months pregnant, and family members said when they finally found the child days later she was unconscious.
"I'm seeing a lot of cases of grief," said Dr Sonam Tobgay, a psychiatrist with the Bhutanese team. "Though they themselves were injured, I can see they've lost their family members. I see anxiety on every second or third face."
The "acute grief reactions", Tobgay said, can develop in the long-term into anxiety, post-traumatic stress, and adjustment disorders, depression, and suicide cases.
|Jeet Badhadui Tamang, 21, with his wife Laxmi who suffered a fractured pelvis and lost her baby [Annette Ekin/Al Jazeera]
One of Tobgay's patients is Pemba Tamang, 52, who worked as a porter.
He was carrying goods when a rock from a landslide struck his lower right leg causing a fracture wound. By the time he was rescued, gangrene had set in, and his leg was amputated below the knee.
It took two days to convince him to get the operation, said Tobgay, because he was anxious about losing the ability to do the only job he had ever known - and losing his only source of income.
Tamang said he's worried about how he'll earn a living in the future, and has insomnia. Lying in a hospital bed, Tamang said he's also concerned about his four children, whom he hasn't heard from since the earthquake.
Krishna Ghimire, deputy director of the Nepal Red Cross Society's first aid division, said many people are experiencing grief at losing loved ones and anxiety about lost homes and displacement.
But prolonged instability about where to live and lost income could pose a "creeping disaster", he said from the Kathmandu office.
For the past four days, 17 Nepal Red Cross volunteers have provided pschyo-social support at sites in the Kathmandu Valley.
The organisation is mobilising volunteers for an 18-month to two-year plan focusing on longer-term mental health needs.
Ghirmire said it's important that mental health workers don't visit people empty-handed, and bring tangible items, such as food, that also support people directly.
"If we go with bare hands it could be more traumatic for them," he said. "Only just talking with them they might not tolerate us."
|Three-year old Karna Tamang lost his thumb and two fingers on his left hand [Annette Ekin/Al Jazeera]
Ghirmire said once short-term foreign relief aid ends, the authorities must step up. "[The] government should say, 'We are here. Don't worry.' This type of commitment is needed."
Dr Frank H Paulin is deputy representative for the WHO country office in Nepal and specialises in public health.
Speaking at UN House in the capital, he said for the past three years WHO has worked with the Ministry of Health to support mental health outreach clinics in Sindhupalchowk, Dhading and Nuwakot - three of the districts badly hit by the quake.
These clinics have treated patients and allowed them to continue living in their villages, but the deadly temblor has disrupted this support system, said Paulin.
In earthquake-affected areas high in the mountains, there are many instances of grandparents living with grandchildren whose parents work abroad.
"A lot of these older people, they are really in danger of suicide," he said. "They need medication, not only psychosocial services support."
Rehabilitation, physiotherapy, and assistance for people with disabilities are areas of health that have been traditionally neglected in the country's periphery areas and must now be developed, said Paulin.
|Quake survivor describes his ordeal
Other health services that have been diverted in the aftermath of the quake, such as immunisation and tuberculosis treatment programmes and the monitoring of measles need to continue, he said.
Yet Paulin is optimistic, pointing to the "tremendous spirit of togetherness" he has seen in the country, including dedicated health workers.
"Health staff haven't just run away," he said.
"Despite the earthquake and despite health centres falling down, you everywhere see nurses, health assistants, doctors treating patients under tarpaulins."
Source: Al Jazeera