Setting

The study took place in Nepal, a country in South Asia with a population of 29.1 million. Nepal has a federal government system comprising 7 provinces and 77 districts. The study focused on Jhapa, Chitwan, and Kailali districts, which are known for their diverse populations and access to mental health services. Nepal’s healthcare system includes public, private, and NGO sectors, with a limited number of mental health professionals. Traditional healers continue to play a significant role, particularly in rural areas. While mental health services are more concentrated in urban areas, these districts have primary healthcare providers trained in World Health Organization’s mental health gap action program intervention guide (mhGAP-IG) along with some resources for mental health care.

Study design

The study used a qualitative design to explore participants’ perspectives on the causes of depression or anxiety, how symptoms manifest, and the factors influencing seeking help from different providers. Qualitative research allows for a comprehensive examination of a topic with limited existing research and encourages participants to contribute to new knowledge [27]. Individual interviews (IDI) were conducted to delve into personal experiences and challenges, as they provide depth, flexibility, and the opportunity to establish a confidential and trusting relationship.

Participants, sample size and sampling process

The study involved adults undergoing treatment for depression or anxiety from trained primary healthcare providers, psychosocial counselors or mental health specialists. To ensure the trustworthiness of the qualitative study, we adhered to Lincoln and Guba’s criteria [28], which included conducting the study in various districts to ensure diversity in terms of caste/ethnicity, cultural practices, and geography. We collaborated with different service providers for participant recruitment, employed experienced interviewers of the same gender as the participants, involved multiple individuals in data analysis, and employed thematic and framework analysis methods. A total of 24 participants were enrolled, with 13 diagnosed with depression, 9 with anxiety disorder, and 2 with both conditions. Seven participants were from Kailali, four from Chitwan, and thirteen from Jhapa district. Recruitment sources included primary healthcare providers (7), psychosocial counselors (7), and psychiatrists (10). Participants were purposively selected based on pre-defined criteria which included being 18 years or older, currently receiving mental health treatment from primary healthcare providers, psychosocial counselors, or mental health specialists, capable of providing informed consent, and proficient in Nepali.

Recruitment and interview process

Two researchers with university degree and several years of experience in qualitative research conducted interviews, pairing interviewers and participants by gender to reduce potential bias. The researchers received two weeks of training, which covered qualitative interviewing techniques, inclusion and exclusion criteria, and an orientation to the interview guides, with particular emphasis on using non-stigmatized terminologies and maintaining confidentiality throughout the interview process and data handling. The first author supervised the interviewers by reviewing audio recordings and providing feedback regularly. Trained interviewers visited participants at homes, explained the study’s objectives, benefits, and risks, and obtained written consent. Interviews were conducted either at home or in a confidential space in the outpatient department at a health center. All interviews were audio recorded in participants’ own words and lasted 45–60 minutes, depending on the depth of information shared. The interviews took place between January 20, 2023 and July 4, 2023.

Interview guides

We adapted the McGill Illness Narrative Interview (MINI), a semi-structured interview protocol commonly used in mental health research, to collect detailed narratives on symptom experiences, illness narratives, perceived causes of illness and help-seeking behaviors [29,30]. The interview guide comprised five sections: history and understanding of the illness, effects and perceived causes, experience of stigma and discrimination, treatment pathways, and barriers and facilitators to treatment. Prior to data collection, the interview guide underwent pilot testing with a small group of participants. This paper focuses on data related to symptoms experienced, perceived causes and treatment pathways.

Data management and analysis

All interviews were audio-recorded, transcribed verbatim into Nepali by the interviewers immediately after each interview, and later translated into English for analysis. The first author reviewed all transcripts against the audio-recordings to ensure accuracy and preserve culturally embedded meaning. Idioms of distress were translated to achieve conceptual rather than literal equivalence, with consultation from an experienced psychiatrist. Two researchers who were involved in coding and data entry independently reviewed all transcripts for initial familiarization.

Data were analyzed thematically using NVivo (version 20). The process began with open-coding of two transcripts to generate initial codes. These initial codes guided the development of a structured coding framework and codebook, which included parent and child nodes with definitions and quotations. Parent nodes covered major analytic domains, such as somatic, emotional, cognitive, behavioural, and cultural expressions of distress, perceived causes, and treatment-seeking pathways. Child nodes represented specific idiomatic expression; translated into English descriptors while retaining the original Nepali terms in italics for nuance. Multi-coding was employed when excerpts related to multiple domains (S1 Table).

Coding consistency and thematic saturation were monitored throughout the analysis. Inter-coder agreement was assessed by having two researchers independently code six additional transcripts. Discrepancies were resolved through discussion with the first author and a psychiatrist to ensure clinical and cultural validity. Inter-coder reliability was confirmed before proceeding with coding of the remaining transcripts (Cohen’s kappa = 0.71). Thematic saturation was reached when new codes or concepts stopped emerging, and thematic patterns stabilized across cases. After cross-case thematic analysis, individual interviews were examined holistically to explore co-occurring symptoms and help-seeking.

Reflexivity

The authors’ backgrounds and expertise in clinical psychology, psychiatry, and global mental health may have shaped the framing and interpretation of the data, potentially highlighting biomedical and service-focused perspectives. To counteract this potential bias, the team engaged in ongoing reflexive practice, challenging assumptions, collaboratively reviewing coding, and addressing both clinical and cultural biases. Input from local experts and regular interdisciplinary discussions supported culturally sensitive interpretations and helped maintain fidelity to authentic local expressions of distress and help-seeking.

Ethical Statement

This study was conducted in compliance with the Declaration of Helsinki and received ethical approval from the Nepal Health Research Council (NHRC) (Registration number: 527/2022 P). Each participant signed a written informed consent before enrolling in the study. Only those participants who voluntarily agreed to participate were included in the study.

Symptoms experienced

Participants reported experiencing a combination of emotional, cognitive, and somatic symptoms. Initially, they experienced fearfulness, anxiety, restlessness, irritability, and heightened startle responses. Low self-confidence, social withdrawal, persistent sadness, and feelings of hopelessness were common. For example, a 60-year-old retired teacher shared his anxiety, worry, fear of crowded places, and feeling of overwhelming responsibility. Despite these challenges, he only discussed concerns about palpitation and tension with his family.

I used to constantly feel scared and unhappy. Minor issues triggered self-doubt and deepened my sadness. Spending nights alone in a small hut heightened my loneliness and anxiety. I struggled to interact with others, had difficulty remembering things, and experienced disrupted sleep. I felt adrift and disconnected, lacking energy for daily activities and finding no pleasure in anything. Social gatherings filled me with fear and anxiety, and I questioned my value and purpose in everyday tasks. It was a challenging period, but I’m grateful to have overcome it. P9

Somatic symptoms such as headaches, gastrointestinal issues, and fatigue were also often mentioned as secondary effects of psychological stress. Some participants described specific symptoms, while others experienced a range of physical symptoms affecting different body systems, such as fainting, trembling, heaviness in the body, and difficulty breathing.

A 30-year-old married Tharu male facing financial difficulties, bereavement, and ongoing caregiving responsibilities, reported significant physical and psychological distress. His symptoms included generalized weakness, gastritis, sexual dysfunction, and a persistent fear of imminent death.

Initially, I experienced gastritis followed by a sensation of coldness in my left leg that gradually spread upwards. My nerves weakened, rendering my body unable to function properly. Subsequently, I began to experience intense headaches, chest pain, body tremors, and difficulty breathing. P2

Similarly, a 47-year-old male migrant worker shared a similar experience, feeling pressurized to work despite being ill and concerned about job and financial security. He described experiencing sudden bouts of dizziness, fear, shortness of breath, and a feeling of impending death.

While I was overseas, I encountered a strange problem. Whenever I was in a vehicle or trying to sleep, I would feel like the vehicle was moving on its own or reversing. This sensation would startle me awake, but then I would drift back to sleep. There was a moment when I felt a shock, as if the vehicle was in motion, and it frightened me. After some time, I would eventually fall back asleep. I would wake up abruptly, struggling to breathe. My chest felt constricted, making it difficult to take in air. I was afraid that I might not survive, recalling a Bengali friend who had died in a similar manner in my room. I experienced intense dizziness, feeling like the room was spinning, and I called out to my friends for help. They didn’t believe me, assuming it was due to alcohol. As I battled the dizziness, I couldn’t shake off the fear of meeting the same fate as my friend. I decided to take a cold shower to snap out of it. The cold water jolted my system. P16

Less common symptoms included dissociative episodes, where participants described brief periods of feeling detached, experiencing amnesia for certain events, or perceiving distortions such as shadows or a sensation of presence. While not experienced by everyone, those who did experience dissociation found it unsettling and sometimes confusing, with some noting a temporary loss of control over their body or surroundings. A smaller group of individuals associated these episodes with intense fear or panic, and a few linked dissociative experiences to instances of self-harm or unusual physical movements.

I used to feel scared when I encountered ghosts, even though I was not scared when I went to the forest with my friends. People around me thought I was crazy. I had to confront ghosts not just at night but also during the day, and over time, this fear grew. I believe that fear is my illness. Right now, I am able to laugh and talk to you without any fear but when this illness resurfaces, the fear will return. P19

Perceived cause of illness

Participants reported a variety of reasons for their distress or anxiety, often stemming from multiple life stressors that overlapped. Financial difficulties such as debts, the inability to repay loans, and managing household responsibilities, especially after the loss of a primary earner or during lockdowns, were frequently mentioned. Bereavement was also a common factor, with participants citing the death of father, husbands, in-laws, and siblings, sometimes compounded by other ongoing stressors. Trauma-related events such as abortion, sexual harassment, and childhood fears were also mentioned in some cases. Participants often connected multiple causes, indicating that distress was perceived as a result of intertwined financial, relational, health, and cultural factors rather than a single identifiable source.

A 47-year-old married woman shared the losses her family had faced since her husband disappeared after being arrested by the Nepal Army during the Maoist conflict. She expressed ongoing fear from past army harassment and current household stressors that were contributing to her emotional distress.

I have lost my father-in-law and husband, and tragically, my youngest brother-in-law has passed away. My middle brother-in-law has also caused a lot of trouble. It’s hard to describe how challenging our situation has been. He took out multiple loans using our family property as collateral, and when he couldn’t repay the interest, the bank threatened to auction off our property. It was a nightmare for me, and I couldn’t understand why this was happening to us. My mind was not functioning properly and I couldn’t comprehend why we were going through this. P12

Several participants believed that the problems they experienced were caused by spiritual or supernatural forces, such as possession by ghosts. One female participant described how the spirit of her husband’s first wife was causing trouble for her.

My husband’s first wife died by hanging herself, and her spirit keeps appearing, trying to take over my body. Sometimes, her spirit attacks me with convulsions, but I was not initially scared. I struggle witheating, moving, falling, and losing consciousness. When I start to fall, my husband accuses me of bringing illness from my family home, tells me to go back there, and even chases me and beats me. P17

Health care practice

Participants in the study reported diverse help-seeking practices, reflecting both biomedical and traditional approaches. Initially, the majority (18 out of 24) sought care from biomedical providers, such as private clinics (n = 5), government hospitals (n = 2), private hospitals (n = 1), primary health care facilities (n = 4), healthcare facilities in a neighboring country (n = 5), and health camps (n = 1). In contrast, six participants (25%) initially consulted traditional healers.

Treatment pathways and practices varied based on symptom presentation. For those experiencing dissociative episodes (n = 7), the majority (n = 4) first sought help from a traditional healer, while others went to a government hospital (n = 2) or sought care in a neighboring country (n = 1). Participants with physical complaints (n = 6) typically started at a private clinic (n = 3), followed by facilities in a neighboring country (n = 2) and a primary health care facility (n = 1). Those with cognitive or emotional symptoms (n = 7) had mixed pathways, with some starting at private or government hospitals, while others visited primary health care facilities or traditional healers.

Subsequent consultations revealed dynamic and iterative patterns of care-seeking, with individuals frequently alternating between traditional, private, and public healthcare providers. While government hospitals and primary health care facilities were not typically the initial choice, they were often utilized for subsequent visits. Some participants integrated biomedical care from other countries with local services, while others alternated between primary health care facilities and traditional healers.

Table 2 summarizes the number of visits participants made to different types of providers. Each visit was counted individually; for example, if a participant visited the same provider twice, regardless of the sequence of visits, this was recorded as two separate visits. Traditional healers were the most frequently consulted providers, followed by private hospitals, and primary healthcare facilities. Visits to neighboring countries and attendance at health camps were less common but still represented components of some care trajectories.

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Table 2. Number of visits with different service providers.

https://doi.org/10.1371/journal.pone.0347605.t002

Participants attributing symptoms to bereavement (n = 9) or family conflict (n = 11) often used both systems, though biomedical care was somewhat more common. Similarly, those citing financial stress (n = 12) showed mixed patterns. In contrast, trauma and culturally rooted fears (n = 11) strongly favored pluralistic care, with ten participants consulting both healers and biomedical providers.

Socio-demographic factors showed limited influence on help-seeking practices. Both men and women predominantly sought biomedical care in their first consultation (8 out of 9 males; 10 out of 15 females). Healthcare facilities were also the preferred choice across age groups: all younger participants (<30 years, n = 5), most middle-aged participants (30–50 years, 10 out of 14), and the majority of older adults (>50 years, 4 out of 5) initially consulted biomedical providers, although many later diversified their care.

Caste and educational status, however, showed clearer variation. Fewer Dalit and marginalized caste participants (4 out of 7) sought biomedical care initially compared to Brahman/Chhetri (10 out of 12), Janajati (1 out of 2), and all the Tharu participants (3 out of 3). Education strongly shaped pathways: all participants with Grade 12 or higher education (9 out of 9) first consulted biomedical providers, compared to only 60% (9 out of 15) of those with Grade 10 or lower education. Occupational differences were also observed; 12 of 14 participants employed in professions such as teaching, business, or foreign employment first sought biomedical care, whereas only 6 out of 10 participants engaged in agriculture or household work did so.

The study participants reported a wide range of emotional, cognitive, and physical symptoms, with fear, anxiety, sadness, restlessness, and hopelessness being the most common. Cognitive difficulties included memory issues, social withdrawal, and a sense of purposelessness, while physical complaints such as headaches, disrupted sleep, gastrointestinal problems, fatigue, chest pain, and dizziness reflected the physical burden of stress. Some participants also described dissociative episodes, often associated with fear, panic, or self-harm. The distress was linked to various life stressors like financial difficulties, loss of loved ones, family conflicts, caregiving responsibilities, trauma, and culturally ingrained fears, with some participants attributing their symptoms to supernatural causes. Participants used a mix of healthcare practices, engaging both biomedical and traditional systems. Most participants initially sought biomedical care while some consulted traditional healers. Many participants switched between providers, with traditional healers being the most frequently visited overall. Care-seeking pathways varied based on symptoms and perceived causes, but involved a combination of both systems, especially for trauma and culturally rooted fears. Socio-demographic factors such as gender and age had minimal impact, while education and caste significantly influenced initial care-seeking choices. Participants with higher education levels and from higher-castes tended to seek biomedical care first.

The study findings highlighted that depression and anxiety in Nepal are often characterized by a combination of emotional, cognitive, and physical symptoms influenced by cultural factors. Participants frequently reported feelings of fear, restlessness, excessive thinking, fatigue, and physical symptoms such as palpitations, chest tightness, and gastrointestinal upsets. The physical symptoms reported in our study are consistent with previous research indicating that in Nepal, expressing distress through physical symptoms is more socially acceptable than discussing emotions directly, due to the stigma associated with mental health issues [31–33]. Fear and negative thoughts were identified as key cognitive symptoms exacerbating anxiety and depression, reflecting culturally significant ways of expressing distress [34].

Participants’ explanatory models were influenced by culturally ingrained fears and supernatural beliefs, leading many to attribute their symptoms to spirits or other malevolent forces. This often led them to seek initial consultations with traditional healers, a pattern consistent with previous studies [24,35]. Consequently, traditional healers were the preferred first point of care for many participants, especially those who believed their symptoms were linked to supernatural forces, trauma, or culturally defined illnesses. Even after accessing biomedical services, many individuals continued to consult traditional healers, a pattern commonly observed among people seeking mental healthcare [24,36]. This underscores the enduring cultural trust and significance of traditional healing practices in Nepali communities, where spiritual explanations for mental distress remain highly influential [37,38].

Pluralistic care-seeking, involving both traditional healers and biomedical providers, was common, especially for trauma and culturally attributed causes. Participants often sought care from both traditional healers and biomedical providers, either sequentially or simultaneously, reflecting a practical and culturally informed approach to managing distress. Traditional healers were typically consulted first for issues perceived as spiritual or attributed to supernatural forces, while biomedical services were sought for physical symptoms or when traditional treatments did not yield results. This is consistent with previous studies in Nepal that have shown mental health care pathways often incorporate both cultural and biomedical elements [39–41]. Similar pluralistic practices have been observed in other South and East Asian contexts, where culturally relevant beliefs influence help-seeking behaviors and treatment adherence [42,43]. Importantly, this trend aligns with broader research on consumer behavior in healthcare, which suggests that individuals actively evaluate and seek value from multiple care options rather than passively receiving services [44].

Education and caste play a significant role in shaping individuals’ initial treatment choices. Education strongly influences help-seeking patterns; individuals with higher levels of education are more likely to turn to medical professionals or healthcare facilities compared to those with lower levels of education. Furthermore, individuals with secondary education or higher did not attribute their mental health issues to supernatural causes, instead linking them to factors such as economic hardships, the loss of a loved one, suicide in family, or other traumatic events. This aligns with research in South Asia indicating that education improves mental health literacy, awareness of available services, and trust in biomedical care [45]. Similarly, caste and social status impact access to healthcare services and perceptions of different treatment options, which may explain why individuals from marginalized groups often seek traditional healers as their first choice [46].

Implications

The findings of this study have significant implications for early detection and improvement of help-seeking practices among individuals with depression and anxiety in Nepal. First the study revealed that people in Nepal often seek care from both traditional healers (such as dhami, jhakri, or lama) and biomedical providers, reflecting a diverse and culturally-informed care-seeking approach influenced by cultural beliefs and accessibility issues. Closer collaboration between local health facilities and traditional healers could enhance early detection and mental health outcomes. Establishing reliable referral pathways and providing basic training to traditional healers to recognize symptoms of depression and anxiety could further support early detection and treatment. Second, education, and caste/ethnicity were found to significantly influence individuals’ initial help-seeking decisions. Dalit and marginalized groups experience stigma, discrimination, and limited access to mental health information [47], underscoring the needs for community-based mental health literacy initiatives. These programs should be delivered through accessible and trusted community actors such as mothers’ groups, FCHVs, and traditional healers [39]. Third, the results indicated that bereavement, particularly the loss of loved ones, was a major trigger for depression and anxiety in Nepal’s close-knit family and community-oriented culture. Implementing trauma-informed interventions within communities, such as peer support groups, culturally sensitive grief counseling, and integrating psychosocial support with traditional mourning practices, could help individuals cope with their grief effectively [48]. Finally, family conflicts and financial difficulties were common contributors to depression and anxiety, with women disproportionately affected by domestic violence, intergenerational disputes, and economic hardships. Addressing these challenges requires comprehensive community-based interventions that combine psychological, social and economic/livelihood support. Programs that prioritize conflict resolution, family counseling, and women’s support groups can offer safe environments to address abuse and promote empowerment.

Strengths and limitations

The study has several strengths. First, to the best of our knowledge, this is the first study in Nepal to explore the relationship between symptom presentation, perceived causes of illness, and help-seeking practices. Second, participants were selected from three different regions of Nepal (eastern, central, and western), representing diverse socio-economic backgrounds. Third, the study included individuals with depression or anxiety, recruited through various healthcare providers. Lastly, the use of the McGill Illness Narrative Interview (MINI), allowed for detailed narratives about symptom experiences, illness stories, and help-seeking practices.

The study also has a number of limitations. First, it was carried out with a purposively selected sample size of 24 participants undergoing treatment for depression or anxiety disorders, which may limit the generalizability of the results. Second, participants were still in treatment during the interviews, potentially not providing a complete picture of the treatment process. Lastly, the study was conducted in areas with specialized mental health services which may affect the generalizability of the results to regions lacking these services.