Intensifying efforts to curb depression, anxiety, suicidal behaviour in Nigeria

Recent studies indicate that there are 800,000 suicide deaths yearly, and the 76 per cent are from Low and Middle-Income Countries (LMIC) like Nigeria.

However, current evidence into suicide prevention is largely based on high-income countries (HIC) and suggests more than 80 per cent of suicidal behaviour is linked to psychiatric disorders. Prevention initiatives in LMIC have been relatively neglected to date.

According to a new University of Bristol, United Kingdom (UK) study published on World Mental Health Day, Thursday, October 10, in the journal PLOS Medicine, future treatment and prevention of suicidal behaviour in LMIC should involve a wider range of approaches beyond just the treatment of psychiatric illness.

This study is the first systematic review of the association between psychiatric disorders, such as depression, anxiety and schizophrenia, and suicidal behaviour in LMIC.

An international research team, comprising academics from the universities of Manchester, Birmingham, Sheffield Hallam, Nottingham, Western Sydney and National Taiwan University, analysed data from 112 studies on 30,030 episodes of non-fatal suicidal behaviour and 4,996 suicide deaths in 26 LMIC.

The research, which aimed to address the issue of suicide prevention in LMIC, found 58 per cent of suicide deaths and 45 per cent of non-fatal suicidal behaviours were linked to psychiatric disorders. The study also found that the proportion of psychiatric disorders in suicidal behaviour was highly variable, possibly reflecting between-country differences.

In HIC the treatment of the psychiatric disorder is a key focus for suicide prevention, but this study suggests that a wider approach might be needed in LMIC.

Elizabeth Blackwell Institute (EBI) Vice Chancellor’s Research Fellow at the Bristol Medical School, Dr. Duleeka Knipe, said: “This is the first time we have really been able to take an overall look at what we already know about the association between psychiatric morbidity and suicidal behaviour in LMIC. Our analyses show there is a lot of variability between studies and countries, and this suggests there is no one answer but does support our thinking that psychiatric disorder is perhaps not as important in these settings as in higher-income countries.

“Of course, the treatment of underlying psychiatric illness is important but prevention efforts should also incorporate a wider range of activities which aim to reduce access to lethal means, poverty, domestic violence and alcohol misuse. For example, population-level solutions, such as banning highly toxic pesticides, have been shown to be effective in reducing the number of suicide deaths.”

Professor of Psychiatry and Population Health at the University of Manchester and the senior author on the paper, Nav Kapur, added: “Despite the huge toll of deaths, suicide prevention in LMIC has been relatively neglected to date. Of course, we need more research — that much is clear. But we also need to get on and implement solutions based on what we already know.”

As part of efforts to reduce the rising cases of psychiatric disorders and suicidal behaviour in Nigeria, medical experts have among others called for increased awareness on the significance of suicide as a global public health problem; improving knowledge of what can be done to prevent suicide; reducing the stigma associated with it; and letting people who are struggling know that they are not alone.

The medical experts include, Chief Medical Director, Federal Neuro-Psychiatric Hospital, Yaba, Dr. Oluwayemi Ogun; Coordinator, Suicide Research and Prevention Initiative (SURPIN), Consultant Psychiatrist, Lagos University Teaching Hospital (LUTH), Dr. Emeka Raphael Ogbolu; a Consultant Psychiatrist, Child and Adolescent Psychiatrist, Senior Lecturer, Department of Psychiatry, LUTH/College of Medicine University of Lagos (CMUL), Dr. Yewande Oshodi.

Others are: Consultant Psychiatrist, University College Hospital (UCH), Ibadan, Prof. Oye Gureje; Founder, Non Governmental Organisation (NGO), the Mind And Soul Helpers Initiative (MASHI), Prof. Hope Eghagha; Consultant Child and Adolescent Psychiatrist, UCH, Ibadan, Prof. Olayinka Omigbodun; and the Director-General of the World Health Organisation (WHO), Dr. Tedros Adhanom Ghebreyesus.

Ogun said that prevention was key to averting mental illness, as suicide was becoming common, following increased presentation at hospitals, hence the need to escalate awareness on mental illness.

She noted that the rising unemployment among youths; economic problems and peer pressure, among others, contribute to the soaring cases of mental health in the country.

Her words: “There is no health without mental health, which is one of the cardinals of health, as defined by WHO. There are lots of advocacies going on in churches, mosques and schools, which are promoting mental health and educating the public on issues around it. Citizens should be conscious of their mental health status, as it is a treatable condition.”

The medical director further stated that there are different categories of mental illness, which include schizophrenia, depression, personality disorders, autism disorder in children and mental retardation, among others.

She urged Nigerians to make haste in presenting cases of persistent changes in their normal level of functioning to medical practitioners in order for the situation to be urgently hospital when there is

Ogun explained that symptoms of mental illness might present as such other illness as headache, sleeplessness, anxiety, becoming withdrawn, aggression, drugs and alcohol intake.

According to her, “when you notice changes like these, it is time to present to the hospital. One thing about mental illness is that one has to be observant about individuals’ feelings and behaviours.”

Ogbolu said the need for awareness of mental health remained critical and very important.

He said the statistics from WHO 2015, which stated that 9.5 per 100, 000 people commit suicide, was still the same.

Ogbolu said: “Mental illness is very broad and so, there is no single symptom that applies to all types. Mental illness or psychiatry covers such things as eating disorders, sleep disorders, learning disabilities, mood disorders like depression, personality disorders, substance abuse disorders, to the more severe psychotic disorders and many more conditions. That is why we try to disabuse the notion that it applies only to the mentally ill person that has been abandoned to roam the streets.”

The coordinator said data from SURPIN’s hotlines as at June 2019 showed that the average age of those who called was 27.6 years.

He said: “This is a young population and it should be a cause of concern for all of us. There were slightly more males and the commonest stressor was relationship issues, followed by health and financial issues.

“Mental illness refers to conditions that affect the way a person feels, perceives thinks and behaves, which consequently lead to the suffering of the person or others and prevents the person from achieving full potential.”

Reacting to the cost of mental health treatment, Ogbolu said persons affected by mental illnesses pay out-of-pocket for treatment, which makes it even more difficult.

He said being covered by the National Health Insurance would bring succour to many, as well as have a broader effect of creating a healthier nation.

He charged the public to stop the stigma towards mental illness, noting that no one is immune. He encouraged people to seek early treatment.

Oshodi told The Guardian there was not enough awareness on Child Adolescent Mental Health (CAMH) in Nigeria.

For Oshodi, many parents and teachers are ignorant and often miss the telltale signs, when a child needs mental health support or even hinder the children from getting mental health help when needed.

She said: “Often, clear causation is not known, so, we may have an interplay of risk factors. Some of these risk factors may be intrinsic like genetics and some environmental such as perinatal complications, temperament, parental upbringing and modelling, trauma.”

The consultant psychiatrist said: “Children and adolescents could be suicidal. In fact, WHO has stated that suicide is the second leading cause of death in adolescents worldwide. It is a very sad statistic and suicide prevention strategies are needed in our communities to mitigate these unfortunate incidents. These strategies must be at all levels. We must work with the individual, family, community and the school.”

Oshodi noted that parents should play a very important role right from birth, provide secure and safe upbringing and development of secure attachments, prevention of abuse, setting limits and boundaries, providing adequate supervision and prevention of substance abuse.

She explained that a good childhood goes a long way in promoting good mental health, not only for children and adolescents today but also for the adults of tomorrow.

The expert said long-term compliance with treatment, as well as the shame and stigma hinder people from going for treatments.

Oshodi said World Mental Health Day celebrated every October 10 was an invitation to all to join hands to fight suicide and poor mental health in the society.

Meanwhile, the WHO has said every 40 seconds; someone loses his or her life to suicide.

Also, the WHO DG has inaugurated a concept tagged, “WHO Special Initiative for Mental Health (2019-2023): Universal Health Coverage for Mental Health.”

Ghebreyesus said: “There can be no health or sustainable development without mental health. Depression and anxiety disorders cost the global economy US$1trn yearly. We record 800 000/year deaths from suicide, which is a leading cause of death in young people. Mental health conditions cause one in five to live with a disability. It is common among people affected by communicable diseases, such as Human Immuno-deficiency Virus (HIV) and Tuberculosis (TB) and non-communicable diseases, including cancer and cardiovascular diseases.

“Treatment coverage is extremely low, especially among populations affected by humanitarian crises and other forms of adversity, for instance, sexual violence. People with mental health conditions often experience severe human rights violations, discrimination and stigma.”

Ghebreyesus said the first strategic action was advancing mental health policy, advocacy and human rights. The second strategy was scaling up interventions and services across community-based, general health and specialist settings.

He said the goal was that by 2023, universal health coverage (UHC) would have ensured access to quality and affordable care for mental health conditions in 12 priority countries to 100 million more people.

Ghebreyesus said the special initiative was designed with multiple assumptions, which include priority efforts needed to integrate mental healthcare across all levels of healthcare, including community, primary, non-specialist hospital, and specialist services. Such integration of care will be critical to achieving universal health coverage and ensuring optimal reach to as many individuals, families and communities as possible.

There was also a need for affordable services and interventions for mental health conditions, which do not expose patients to financial hardship, but focusing across the life-course, and leaving no one behind. These include women, men, girls and boys across cultures, contexts, health conditions and in all phases of life, among others.

Gureje said that eliminating mental health stigma would encourage affected persons to seek treatment and boost the quality of life.

Gureje added the challenge with depression is that people who are affected are not aware of their conditions, let alone getting treatment.

“It is also unfortunate that most symptoms will present themselves like malaria and before one will understand exactly what is happening, depression would have eaten deep. Symptoms of mental health include irritable mood, low concentration, low self-esteem, guilt, among others,” he added.

Ogbolu noted that the initiative is positioned to reduce the risk of suicide arising from mental health and chronic general medical conditions, through ingenious community-based approaches, cost-effective crisis intervention, improved suicide record keeping, and high-quality suicide-related research and education in Nigeria.

“We are positioned to be the reputable, reference centre body coordinating and maintaining global best practice in suicide research and prevention activities in Nigeria, ultimately to reduce the rate of suicide,” he added.

The coordinator said Nigeria is expected to heed the call of the WHO to join hands in reducing the world suicide rate by ten percent by 2020. “In this collaborative effort, Nigeria requires functional suicide research strategies. There is a glaring lack of up to date records on suicide, yet available data so far shows that suicide is not alien to Nigeria.”

The psychiatrist said that relying on statistics from WHO Global Health Observatory Data, suicide in Nigeria is at an estimated rate of 9.8 per 100,000 higher than regional average stressing that action is needed especially considering that the rate is an underestimation as many cases go unreported and undocumented.

Ogbolu continued: “The fact we have others, who might talk about suicide prevention, we talk about research and prevention and the reason why research is important is you cannot talk about solving your problem if you do not know the extent of your problem. Otherwise what you just do is to adopt somebody’s approach to prevention and start to use it and it may not be ideal for you.”

Eghagha said they have been concerned about the rate of suicide in Nigeria because it is now something of public attention when young men and women started taking a plunge from the third mainland bridge into the lagoon.

To tackle the menace, Eghagha said they started a discussion group, worked with a lot of professionals, counsellors, psychiatrists, psychologists, nurses, and enthusiasts, people who are also concerned in the area of suicide prevention.

According to the Ogbolu, “from research, we found out that we cannot do suicide prevention without engaging religious leaders. This is because we looked at the dynamics of parts to care. When Nigerians are ill, how do they go before they get to the hospital? They go through their spiritual leaders or herbalist. So, this is the importance of research. You just do not dive into something.  You have to find out what evidence supports that. So that is what made us unique.” 

He added: “Again because we are operating from a point of view of a federal institution. We have the goodwill of other federal institutions. What we have done, if you call our hotline, for instance, from Kano, we have a psychiatrist in Kano because we cannot treat you from here (Lagos). We now link you up. We have other mental professionals who are partnering with us all across the country.”

The consultant said SURPIN is the only structured suicide prevention. “It is structured such that we have zonal people to contact. You can be anywhere and we link you up with the nearest available mental health expert. We are a research and prevention initiative. The research component is important for national coverage.”

Ogbolu added that the initiative is facing challenges of funding, stating that much work is needed to be done to decriminalise suicide in the criminal code of the country and address the stigma associated with mental health conditions which may put people at risk.

Omigbodun said there is a universal intervention in preventing depression and suicide in children and adolescent to promote mental health and wellbeing and child adolescent mental health.

She called for the review of mental health laws to provide proper care for affected persons in Nigeria. “We cannot talk about the proper treatment of mental health issues if we do not have a law to back it up and we also need to understand that mental health issues affect everyone.”

The psychiatrist added that the burden of depression on adolescents affect their interpersonal relationships and could be linked to other problems including smoking, drug abuse, academic failure, physically inactive and secondary behavioral problems like truancy and stealing.

Eghagha said at MASHI, they report suicide cases; we take calls from persons who are depressed, use the telephone to counsel people and when the need arises for a referral they refer them to hospitals and the individual talks to a psychiatrist.

He continued: “One of the things to do is to create awareness among young people. We have started a series of lectures among young people in secondary schools. We take a professional who talks to them about suicide. We need to inform and educate people about suicide; we need to counsel and clear minds of people against the stigmatisation that comes with seeking help.

“We need to do a documentary, in English and translate it to different languages and our partners across the country will play this in radio stations in the languages educating people. We also try to do talks, visiting the churches, mosque, and school anywhere there is assembly we talk to them and educate them about mental.

“Our plan is ultimate, there should not be a mad person in the streets of Nigeria because they do not have to be there. What we have tried to do is to recruit people who are helpers, we have to create helplines for them across the country so that when you’re going through that kind of distress you call, they talk to you, and we are trying to establish a network with all the psychiatric homes in Nigeria.”

He disclosed that when people have a psychological breakdown, there are all kinds of reason attributed to it. The most popular one in the country is a spiritual attack. Sometimes, they say you have offended the ancestors or the village people, that you have committed an act of taboo. You find some highly placed educated people still piloting such ignorance.

“We realised that one thing we need to do is to educate people that mental health is very important and mental health crisis can affect anybody without committing any offense and it does not need to be a spiritual attack. We come from a very superstitious society. We are looking at it from the scientific point of view that somebody who contemplates suicide, somebody with suicidal thoughts can be helped,” he added.

Shading light on how suicide tendency can be identified, the MASHI boss continued: “For some people, depression starts slowly. They begin to question themselves; they question their identity. Who am I? What am I doing in this world? Why is it that I have been forsaken? Why has the Nigerian state treated me like this? They ask these questions with no answers. “Gradually it leads to depression.  They don’t reason properly anymore.  For some, they attempt to commit suicide. It affects young people but as we know the age, status, wealth is no barrier or protection to mental health it can happen to anybody.”