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‘Mental Healthcare must be patient-centered and affordable’

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Tunde Ojo


Dr Tunde MasseyFerguson Ojo is a mental health specialist with experience in mental health promotion, prevention and management of mental health conditions using psychotherapy, counseling and pharmacotherapy, among others. As Nigeria joins the rest of the world to mark the Mental Health Day today, the consultant psychiatrist and Head of department of Mental Health, University of Abuja Teaching Hospital speaks with TOBI AWODIPE on misconceptions about mental health increase stigma and discrimination against patients, causes of mental health problems and why there is dearth of psychiatrists in Nigeria, among other issues.

The theme for this year’s mental health day is Mental Health for All, Greater Investment – Greater Access. In terms of investments, how much have we invested in mental health awareness and advocacy in Nigeria?
There has been an increase in mental health awareness and advocacy in Nigeria in recent times especially with the surge in availability of electronic platforms and social media; however, individuals and non-governmental organisations drive most of it. There is need for government to play a leading role in mental health awareness and advocacy. This is important because misconceptions around mental health are what drive the high level of stigma and discrimination towards it. This is what is in turn responsible for the large treatment gap for mental health problems, as many affected people will not seek for the correct treatment due to the erroneous belief that mental health problems are spiritual attacks resulting from bewitchment, among others. It is very important that government and other stakeholders increase investment in mental health and advocacy.

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Do we have sufficient access to mental healthcare for all?
A quality mental healthcare must be patient-centred, evidence-based, accessible and affordable. We have evidence-based treatments and to an extent, I will say our mental healthcare is affordable when compared to other climes. However, the major problem with our system is that most patients and relatives have to pay out of their pockets because the coverage of mental health conditions under the health insurance is at best, not comprehensive and at worst, a mirage. Access is about our biggest challenge in mental healthcare in Nigeria. Only about one in every 10 persons that need treatment ever gets it. The reason for this is the inadequacy of the resources needed.

For a country of over 200 million people, there are only about 250 psychiatrists, one to almost a million people. There is also shortage of other mental health professionals like clinical psychologists, mental health nurses, social workers and occupational therapists, among others. Another big problem closely associated with this is the uneven distribution of available scarce resources. Most human resources and mental health facilities are concentrated in few cities across the country whereas people that need the care most are in the rural areas. Mental health is peculiar compared to other areas of healthcare delivery because of its emphasis on the biopsychosocial approach to treatment thus necessitating the use of multidisciplinary teams in management. One in four people would have mental health problems in their lifetime. The scarcity of the human resources for mental health care is not just among the doctors but also across all cadres of healthcare workers. Despite the inadequate human resources, health workers working in this sector are leaving for greener pastures in droves because of poor conditions of service here.

What exactly is needed to enhance mental care delivery?
First, the right mental health policies need to be in place. Nigeria has had only two mental health policies since its existence. The last one was in 2013. Unfortunately, none of the policies were ever implemented. The policy is supposed to be reviewed every five years, so even the last one that was never implemented is long overdue for review.

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The policy must make integration of mental health into primary care one of its pillars. It must also put emphasis on multisectoral approach to tackling the issues of mental health involving all sectors including but not limited to housing, finance, poverty eradication and community development, education and health.

Equally important is the role of legislation. Legislation is what gives legal backing to policy thereby making it enforceable. Many policies in Nigeria never get implemented because there is no law backing them. The mental health law operating in Nigeria is the Lunacy Act, which is a very archaic law and has sadly been in operation for over 60 years, but doesn’t reflect the current global reality in the delivery of right-based quality mental health care. There have been previous unsuccessful efforts to address this. The current leadership of APN with other stakeholders in mental health has rallied support to ensure passage of the bill, which has now passed second reading. When both the policy and legislation are in place, many of the concerns in the delivery of quality mental health care would have been addressed.

Can you share with us some primary causes of mental health disorder?
There is no single cause; they are multifactorial, an interplay of a lot of factors including biological, environmental, economic and psychosocial factors. Culture plays an important role in the explanation of mental health problems and the health seeking behaviour of people. In Nigeria as in other low and middle-income countries, culture has not played a positive role in mental health. Cultural beliefs have always attributed mental health problems to spiritual causes like attacks from household enemies, ancestral curses, bewitchment, demons and life failures. This has led to stigma and discrimination towards sufferers, making it difficult for them to access care. Many people patronise faith and traditional healers with poor outcomes.

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What are signs of a mental health breakdown?
Like any other medical conditions, there are signs and symptoms that act as pointers to poor mental health. But they differ based on the type of mental health problem. Common ones include insomnia, decline in occupational functioning and maintaining interpersonal relationships, decline in personal hygiene, persistently low mood, loss of interest in usually pleasurable activities, feelings of hopelessness and helplessness. Others include having unusual experiences like hearing voices and suspicion of others always having evil intentions towards you.

How can mental health disorder be addressed?
When people talk about mental health, what usually comes to mind is treatment. But the right approach to mental health is a holistic one, which takes into consideration promotion, prevention and treatment of mental health conditions. Mental health problems are preventable if people are informed on how they can maintain optimal mental health, what they can do to maintain their mental wellbeing and what they can do to prevent mental health problems. It will go a long way in reducing the burden of mental health in our society. If that approach is used, we will be tackling the problem upstream rather than when it would have already become a disease needing treatment.

Are there activities that can improve one’s mental wellbeing?
There are a lot of activities than can contribute to our mental wellbeing like eating well, regular exercise, good sleeping habit, maintaining good interpersonal relationships with people, engaging in religious activities, keeping routines, mindfulness, giving to others, volunteering and avoiding recreational drugs.

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The world is slowly recovering from COVID-19, what notable impact did it have on the mental wellbeing of people?
COVID-19 has affected all areas of our lives in every way and the mental health of people is one of those significantly affected. During the height of the pandemic, there was increased rate of mental disorders like insomnia, anxiety and depression. There is a lot of anticipatory fear of being infected, which had negative impact on mental wellbeing of people. The high volume of fake news and reporting of mortality associated with the pandemic also impacted negatively on the mental health of people. A lot of people that lost loved ones may have prolonged grief period. There is also increased rate of post-traumatic stress disorder (PTSD) during and after the pandemic.

The isolation and lockdown that were used to control the spread also affected the mental health of people causing loneliness and boredom. Associated with this is increased likelihood of eating disorder, psychoactive substance use and domestic violence. For people with existing mental disorders, the disruption in healthcare and the lockdown meant that many of them were unable to access care and disrupted logistics caused non-availability or increased cost of medications needed, so many patients had relapse episodes. The socio-economic implications of the pandemic also had a negative impact on mental wellbeing. Healthcare workers are not immune. In fact, they are more susceptible as they are on the frontlines and now is a good opportunity for investment in mental health.

What are the mental health services available here and how accessible are they?
Most services available here is mostly hospital based care. There are specialist psychiatry hospitals in each of the geopolitical zones and department of mental health or psychiatry in each of the universities. Some state also run some mental health services either as standalone specialist hospital or integrated as part of routine service delivery in General Hospitals. The very few facilities available are unevenly distributed as most if not all of them are located in cities thus making access extremely difficult for those who need it but live far away.

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What can we do to scale up mental healthcare in the country?
Government needs to develop the political will to make mental health a priority. Once this is done, scaling up will not be a problem. The political will would translate into greater investments in mental health and the development and implementation of mental health policy backed by appropriate legislation. In the delivery of mental health services, there is need for integration of mental health into primary health care, as the current system of hospital-based care can never adequately address the mental health treatment gap in the country. In order to tackle inadequate human resources, there is the need for the adoption of task shifting as a strategy.

In your opinion, what can be done to address brain drain in this field?
Government needs to create better working conditions for all healthcare workers. Government should explore the possibility of a policy that will ensure the retention of healthcare workers within the healthcare system after graduation. People can be given grants while in school in exchange for retention in the system for a specific period of time.

Government also needs to value its healthcare workers. It is not good when healthcare workers have to strike before being listened to.

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