Mental disorder: How economic, security uncertainties, COVID-19 fuel numbers

Times are hard. The country’s economy is comatose. There is insecurity nationwide. Nigerians are still recovering from the damages done to their health and economy by COVID-19.

Consequently, anxiety, depressive disorders and suicidal tendencies are on the rise. Men, women, boys and girls are losing it. Some have taken to alcohol and other psychoactive substances for solace.

Some have sought help from a few psychiatric hospitals and conventional facilities nationwide. Those who cannot afford conventional care for fear of discrimination and stigmatisation, and because it is not covered by health insurance, have resorted to spiritual help in churches, mosques and traditional medicine homes, where the patient is often violated, chained and abused.

Estimates put the rise in both anxiety and depressive disorders at more than 25 per cent during the first year of the pandemic.

Mental healthcare generally refers to services ranging from assessment, diagnosis, and treatment, counselling and restoring the mental well-being of people.

In Nigeria, there is a significant disparity between the demand and supply of mental health services. Though there are policies aimed at addressing it, in-depth information on the service in Nigeria is non-existent.

This makes it difficult to identify areas of need, coordinate activities of advocacy groups, and make an informed decision about policy direction.

It is estimated that about 50 million people are living with some sort of mental illness, that is, one out of four Nigerians has one mental challenge or the other.

According to Nigerian Medical Association, 350 psychiatrists currently serve Nigerians with an estimated population of about 200 million people.

This is similar to the estimated number of 250 psychiatrists serving Nigerians claimed by the President of the Association of Psychiatrists of Nigeria, Dr. Taiwo Obindo.

Shortage of mental health professionals in addition to inadequate infrastructures and poor public attitudes towards mental illness has resulted in about 80 per cent of people with serious mental illness being unable to access adequate care.

Also, cultural and religious stereotypes have a significant impact on the recovery process of people with mental health issues. Studies by Africa Polling Institute in collaboration with EpiAFRIC found that many Nigerians still associate mental illness with evil spirits, voodoo and related supernatural causes.

According to Nigerian mental health expert, Aisha Bubah, people do not have an understanding of it, as they attribute mental issues to cultural and superstitious beliefs. “And the image of mental health people have is always the extreme cases,” Bubah said.

This misconception has prompted many to seek treatment from religious leaders, traditional healers etc.

In 2019, Human Rights Watch reported that thousands of people with mental illness are living in ankle chains at institutions designed for care.

The recent World Mental Health Day (WMHD) 2022, which was marked on October 10, provided an opportunity to re-kindle efforts to protect and improve mental health.

The campaign on mental health
EVERY year, since 2013, the World Health Organisation (WHO) has organised a global campaign for WMHD. The World Federation for Mental Health (WFMH) announced the theme, “Make mental health for all a global priority”.

Growing social and economic inequalities, protracted conflicts, violence and public health emergencies affect whole populations, threatening progress towards improved well-being.

According to reports, a staggering 84 million people worldwide were forcibly displaced in 2021 by the effects of COVID-19, leading to unstable incomes and mental stability.

“We must deepen the value and commitment we give to mental health as individuals, communities and governments and match that value with more commitment, engagement and investment by all stakeholders, across all sectors. We must strengthen mental healthcare so that the full spectrum of mental health needs is met through a community-based network of accessible, affordable and quality services and supports,” the WHO said.

In Nigeria, psychiatrists have raised the alarm that one in four persons, that is, over 50 million Nigerians, is suffering from one mental disorder or the other.

They said about 75 per cent of those who need mental healthcare do not have access to it and Nigeria has only 300 psychiatrics to treat about 200 million people.

Also, they said Africa has one psychiatrist for every 500,000 inhabitants, which is 100 times less than WHO recommendation.

The psychiatrists said around 11 people per 100,000 per year die by suicide in the African region, higher than the global average of nine per 100,000 people.

They, however, made recommendations on how to reverse suicide and mental health crisis in Africa.

A consultant psychiatrist at Federal Neuropsychiatric Hospital (FNPH) Yaba, Dr. Naya Eghegbara, told The Guardian: “The burden of mental health is increasing, especially in this post-COVID-19 era. Off course, there is a lot of difference, the pandemic brought about so many unprecedented changes and difficulties regarding people’s finances, lots of businesses went down, and there was a lot of anxiety and uncertainties. Nobody really knew or fully understood this virus at the initial stage, and no one knew when the pandemic was going to come to an end. Following all of that, globally, there have been incidences of mental health disorders both in Nigeria and other parts of the world.

“So, the burden really has increased since then and on average, the number of new cases that the hospital has to review on a daily basis has significantly increased as well. The burden on the family is also a lot because once the illness has set in, there is a burden of care and also financial burden where you have to pay for the treatment; so, definitely, and the burden has increased following the pandemic.”

The psychiatrist said there are not enough mental health professionals to meet the needs of Nigerians.

“Be it psychiatrists, psychologists, mental health nurses, or social workers; they are just not enough. So, thankfully, there is a lot of awareness growing regarding mental health issues and more people are accessing care in the right places, but the challenge is that there are not enough mental health workers to meet the needs of teaming population of Nigerians,” Eghegbara said.

“So, if we can focus more on using the preventative approach, it will cut off some of all these other complications. Preventative approach, targeting different age groups; maternal mental health is so important, screening all women who go to antenatal to ensure that even if there are early signs of psychological disorder coming up, it could be quickly addressed and nipped in the bud because once it is established, it affects not just the mother but the child and other family members.”

On the challenges faced by social welfare officers, the Chief Social Welfare Officer at FNPH Yaba, Ajetunmobi Temitayo, said: “Oftentimes, when the police bring in a potential patient at the hospital, they fail to provide the necessary information needed and oftentimes, I have to take the patient back to the police station to get the necessary information.”

Temitayo added: “We all know the state of the country, currently, businesses have failed and folded, and there are a lot of people and anyone could be susceptible to the disorder; men, women, children. Most of the students on strike are depressed and some are now suicidal, not everyone can manage depression. The government needs to intervene to improve living standards in the country,” she said.

How best can Nigeria address the rising cases of suicide?
DR. Passy Amaraegbu, a clinical psychologist, said suicide is the act of intentional ending of one’s life. This is truly a criminal offence.

He said from various research studies available, Nigeria has the highest rate of suicide in Africa, as well as occupies the sixth position in the world. The first five highest countries with suicide are India, China, America, Russia and Japan.

The causes of suicide in Nigeria are identified as, interpersonal difficulties, mental and physical sicknesses and drug abuse among others.

The important question is, how best can this rising ugly incidence of suicide in Nigeria be addressed?

“The first is evolving preventive measures. Prevention is always better than cure. These preventive measures include the following strategies, providing appropriate enlightenment and educational programmes for the populace, and providing financial empowerment for the countless jobless so that their hope for living is restored.

“Also, the various levels of government in Nigeria should take the issue of providing security seriously. A significant percentage of suicide is associated with depression and Post Traumatic Stress disorder ( PTSD). The stress emanating from economic impoverishment and the pain of diverse forms of loss accruing from trauma easily predispose people to depression and, if not handled, ultimately to suicide,” he said.

He added, “family members, religious organisations and employees of labour should be deliberate in their efforts to promote Mental health. We should try and care for each other, be observant and know when someone manifests symptoms of depression and help them to obtain specialist help.

“Also, Nigerians should learn to engage in regular mental health check-ups. All these preventive mental health strategies would help to reduce the rate of suicide in our society.”

In the area of a cure for suicide, he said: “The various arms of government in Nigeria should collaborate with mental health specialists to promote mental health by giving special attention to depression and anxiety disorder patients. Concerted efforts should be made to provide up-to-date equipment and mental health specialists who will focus on the areas of causes of suicide. Any patient who manifests early symptoms of depression or suicide should be given appropriate and adequate attention.

“Mental health specialists should ensure that they use appropriate chemotherapy, psychotherapy and other relevant therapeutic strategies to deal with suicide. Also, mental health specialists should engage in collaborative efforts to help their patients.”

MEANWHILE, FNPH Yaba, Lagos, on Tuesday, October 11, 2022, launched a book in an effort to increase awareness of mental health and wellbeing.

The book titled, “Resilience in Surmounting Adversity” was written by the Medical Director and Chief Executive Officer (CEO) of the Hospital, Dr. Olugbenga A. Owoeye.

Head, of Special Project and Mental Health Lagos State Ministry of Health, Dr. Tolu Agomale, at the event, said mental health is oftentimes misconstrued as mental illness itself.

According to him, mental health includes emotional, psychological and social well-being. It affects how people think, feel and act. It also helps determine how people handle stress, relate to others and make healthy choices.

Agomale spoke about the different programmes created over years to promote mental health and the laws made for the protection of rights of persons with mental illness. He said: “For us, this is now an opportunity to create different programmes that can address this issue and one of them is creating helplines that people can call if they are having mental issues this helpline is available 24 hours where people can call to discuss any of the issues they are struggling with. And we have had thousands of calls on that platform for more than two years now.

“We have also integrated mental health into our secondary facilities so that people do not have to go to specialist hospitals anymore rather they can see a psychiatrist at general hospitals and even primary health centres, where we have trained the health workers to be able to provide mental health services. What they are able to do there is to provide early diagnosis and baseline access to care, then referrals to the general hospital, if need be.”

Owoye, in his speech, said, “the trajectory of human existence today is one bedevilled with so many uncertainties, chaos and upheavals, with resultant effects on the mental health status.”

He also spoke about the pandemic and how it brought about the global crisis for mental health, fuelling short- and long-term stresses and undermining the mental health of millions.

“Estimates put the rise in both anxiety and depressive disorders at more than 25 per cent during the first year of the pandemic and at the same time, mental health services were severely disrupted and the treatment gap for mental health conditions became widened,” he said.

Owoye also emphasised the need to make policies and adequate budgetary provisions for awareness and educating the public on mental health issues.

He said: “As part of giving mental health a global priority, governments across the globe should make adequate budgetary provision in their yearly budget for creating awareness and educating people on mental health issues. Mental health institutions should be adequately funded to perform their role in the treatment and care of people living with mental health problems.”

In his book, ‘Resilience in surmounting Adversity’, Owoeye said: “The various mental illness ranges from the minor conditions to the major ones. Minor conditions like stress-related disorders or acute stress reactions like generalised anxiety; phobias of various types constitute the minor conditions. But when it is becoming major like in the area of affective disorders, either major depression or menial, sometimes it could be in form of schizophrenia.”

There are different types of schizophrenia. There is a split mind, where the mind is shattered and the person loses contact with reality. The person may also be hearing strange voices, seeing strange things, and having odd behaviours. Substance abuse-related disorder is also part of the major condition and this may be comorbid or coexist with some other major mental illness. Other minor conditions include eating disorders like anorexia nervosa and bulimia nervosa.

Owoeye said another challenge is inadequate infrastructure. He said Nigeria has only nine federally owned psychiatric hospitals, and six of them are located in the six geo-political zones. The psychiatrist said there is still a need for more to cover all the states considering how common this condition is.

“I think one federal psychiatric hospital in a state should do for now,” he said.

Obindo said: “Mental healthcare is in a sorry state, given that we have more than 60 million Nigerians suffering from various mental illnesses and the fact that only about 10 per cent of them are able to access appropriate care.

“We are left with more than 90 per cent who cannot access care and this group is called the treatment gap for mental illnesses. Knowing that 60 per cent of Nigerians live in rural areas, they do not have access to appropriate care and have to travel long distances to access facilities.

“We are left with more than 90 per cent who cannot access care and this group is called the treatment gap for mental illnesses.’’

He said the gap was as a result of various factors like the knowledge gap in which people do not have appropriate information about the causes and treatment for mental illnesses.

Obindo also said the number of mental health practitioners falls below the ratio recommended by the WHO.

According to him, the few that were trained were often eager to leave the country.

“The environment in which we practice, the security situation and the remuneration that people were given in the country tend to push them out.

“And then, of course, the pull factor from the developed countries where they tend to poach on the already trained medical practitioners in the country, particularly the psychiatrists,” he said.

Way forward
ON how to improve mental healthcare in Nigeria, a consultant psychiatrist and former Chief Medical Director, of Lagos State University Teaching Hospital (LASUTH), Dr. Femi Olugbile, told The Guardian: “If Primary Health Care (PHC) facilities are activated to recognise and treat basic mental health problems, and if they are interconnected through electronic medical records/Information Communication Technology (ICT), specialists based in specialist centres could supervise these PHCs in regional clusters and facilitate back and forth referral of difficult cases. This is the appropriate pragmatic response to the target, rather than perpetual hand-wringing about the shortage of specialists. Carefully managed task shifting is the way forward, though it should not stop the acquisition of more specialists and facilities. We need to think out of the box.”

On legislation or reform on mental health in Nigeria, Olugbile said: “On Feb 19, 2020, the Nigerian Senate held a public hearing for the Mental Health and Substance Abuse Bill. It is believed that if passed, the Bill would allow for much-needed budgetary allocations for mental health facilities and mental health providers. The passage of the mental health bill will help in every area and open up new possibilities.”

Taming the suicide syndrome
According to the WHO, around 11 people per 100,000 per year die by suicide in the African region, higher than the global average of nine per 100,000 people. It said this is due in part to insufficient action to address and prevent the risk factors, including mental health conditions, which currently affect 116 million people, up from 53 million in 1990.

The WHO, in a statement, said the social media campaign aims to reach 10 million people across the region to raise public awareness and galvanise the support of governments and policymakers to increase focus and funding for mental health programming, including suicide prevention efforts.

The African region is home to six of 10 countries with the highest suicide rates worldwide. The common means of suicide in the region are hanging and pesticide self-poisoning and to a lesser extent drowning, use of a firearm, jumping from a height or medication overdose. Studies show that in Africa for each completed suicide, there is an estimated 20 attempted ones.

WHO Regional Director for Africa, Dr. Matshidiso Moeti, said: “Suicide is a major public health problem and every death by suicide is a tragedy. Unfortunately, suicide prevention is rarely a priority in national health programmes.

“Significant investment must be made to tackle Africa’s growing burden of chronic diseases and non-infectious conditions such as mental disorders that can contribute to suicide.”

According to the WHO, mental health problems account for up to 11 per cent of the risk factors associated with suicide. This year’s World Mental Health Day was marked under the theme “Make Mental Health and Well-Being for All a Global Priority” to draw attention to the importance of mental health care and the need for better access to health services.

The WHO said, in Africa, underinvestment by governments is the greatest challenge to adequate mental health service provision. It noted: “On average governments allocate less than 50 US cents per capita to mental health. Although it is an improvement from 10 US cents in 2017, it is still well below the recommended US$ 2 per capita for low-income countries. Additionally, mental healthcare is generally not included in national health insurance schemes.

“Due to the low investment in mental health services, the African region has one psychiatrist for every 500 000 inhabitants, which is 100 times less than the WHO recommendation. Additionally, mental health workers are mostly in urban areas, with primary and community health facilities having very few if any.”

WHO is supporting countries to step up mental health services in Africa. Primary healthcare workers in Zimbabwe are being trained under a WHO initiative to boost quality and access to mental health services. In Kenya, Uganda and Zimbabwe an initiative to develop country investment cases for mental health services has been concluded and advocacy is underway to mobilise resources. The Organisation is also supporting Cabo Verde and Cote d’Ivoire to carry out national suicide situation analysis as a first step towards devising effective response measures.

In August 2022, African health ministers gathering for the 72 sessions of the WHO Regional Committee for Africa—the region’s flagship health meeting—endorsed a new strategy to reinforce mental health care and set 2030 targets: all countries to have a policy or legislation on mental health, 60 per cent of countries implementing the policy, 95 per cent of countries monitoring and reporting on key mental health indicators and 80 per cent of countries have a budget for mental health services.