Kathmandu: The powerful 7.3 magnitude tremor that struck Nepal this week left an already traumatised population gripped by even deeper fear, underlining concerns that the country is ill-prepared to cope with the mental side effects.
Tuesday's quake caused a fraction of the fatalities inflicted by the huge 7.8 earthquake that killed some 8,000 people less than three weeks earlier, but left millions more frightened than ever.
Binda Dhungel, 31, and her injured son and daughter sat inside a health clinic in the mountain town of Charikot on Wednesday after they walked two hours from their village, which was devastated in the second quake.
"There's not really anyone back in the village. There's no one else there. I don't know how we're going to survive," Dhungel said.
Tuesday's quake killed about 80 people, and destroyed many houses.
Krishna Prasad, 30, a doctor at the centre, says patients are frightened and worried they are not strong enough to go back. The children, he says, are medically fine but "psychologically they look terrified".
In towns and villages across the country the scene was the same: dazed families sitting by cracked or flattened homes, jumpy about seemingly endless aftershocks and landslides from loose hillsides, and uncertain of their future.
Ranveig Tveitnes, deputy team leader of the Norwegian Red Cross in Chautara, said the latest earthquake and subsequent aftershocks had pushed people back from a fragile recovery.
"When they first came, you could see people were dead in their eyes. In the last few days, people started to laugh again. But today people were completely traumatised. Patients grab you and hold you and they don't let go," he said.
As natural disasters often do in poor nations, Nepal's earthquake has exposed the gross inadequacies of its mental health services just at the moment when they are most needed.
Even before the quakes, Nepal had one of the world's weakest mental healthcare systems, with just 100 psychiatrists and about a dozen clinical psychologists to serve a nation of 28 million people, according to government data.
Inside Nepal's only government-run psychiatric hospital a large crack runs down one of the walls caused by last month's quake. The patients live in cramped, dimly-lit wards that reek of urine and trash is scattered around the floor.
The 50-bed hospital in Kathmandu is so overloaded that patients can only stay there for up to a month. They sleep in rusting, metal beds inches apart, and share them with family members who come to look after them.
"The preparation for this type of disaster just wasn't there," said Surendra Sherchan, a doctor who runs the hospital. "The mismatch between the mental health needs and what we can deliver right now is enormous." The disaster has set off reactions ranging from anxiety to psychosis. Gopal Dhakal, a psychologist, says the continuous tremors will worsen depression, post-traumatic stress disorder, nightmares, insomnia, and fears about going inside.
Sanjay Kumar has chosen to live with his children under a tarpaulin sheet in Kathmandu rather than return to his home since the April 25 earthquake, fearing that a more destructive quake is on its way. "If the earthquake had all come at once, it would have been OK, but these small quakes, the ones that keep coming, are really making my heart panic," Kumar said. "My children are scared too and don't want to go back. They want to stay here, out in the open."
Sherchan estimates 4 percent of Nepalis impacted by the earthquake will develop post-traumatic stress disorder.
For those suffering from mental illness there is little help at hand: spending on mental health accounts for 0.08 percent of the health budget. That is the third lowest level in the world after Zimbabwe and India, the World Health Organization reckons.
