Bridging Nigeria’s yawning gap in mental healthcare delivery

Segun is in his mid-forties. Over the last decade, he has been battling some form of mental illness, which has made him uncoordinated and unproductive. The progressive degeneration of his mental state over time has led to loss of job, and rejection by those who once cared about him. Abandoned by family and friends, Segun now lives at the mercy of a not-for-profit organisation, which rescued him from the streets.

While Segun has been fortunate to be taken off the street, catered for, and enrolled for sustained care in one of the nation’s mental health facilities, not many Nigerians suffering the same fate are as lucky. Often than not, the moment they fall into the mental health chasm, they are ill-treated by society, stigmatized, left dejected and allowed to sink deep into the abyss from which they may never recover.

The situation is made more pitiable in a country left with less than 250 qualified psychiatrists when the World Health Organisation (WHO) standard is that one psychiatric doctor ought to care for 10,000 patients. 

For instance, the Federal Neuro-psychiatric Hospital in Yaba, Lagos, once claimed that over 25 per cent of patients on admission were abandoned by their relatives, friends or minders.

Medical Director of the hospital, Dr. Olugbenga Owoeye while lamenting the development, said it was worrisome because the number of abandoned mental health patients in the hospital keeps growing.

“As I speak, over 25 per cent of the psychiatric patients on admission are unable to pay their bills and do not have anybody or relation whatsoever to assist with the payment. Most of these indigent and abandoned patients have lived in the hospital for years and as a result might not be able to trace or locate their families and relatives.”

The medical director appealed to Nigerians to help the abandoned patients to offset their medical bills and meet their daily needs. “We have quite a good number of them who the hospital is currently catering for their feeding, clothing, medication and overall upkeep,” he said.

Persons struggling with different forms of mental health challenge are common sight in public places across the country, from the north, to the east and southern Nigeria.

One major challenge that has been identified by healthcare practitioners in treating mental illness is that healthcare facilities and mental health care professionals are not enough nor well equipped to handle the burden of mental illness patients.

In addition to these, however, there are also several barriers to effective treatment for the mentally challenged. These include the lack of understanding of the root causes of mental illness, lack of financial support to get mental health treatment, lack of social support from family, friends and neighbours; and the fear of stigmatization when labeled as mentally ill or being in association with the mentally ill.

Another barrier is the resort to religious houses and clerics for relief, and the consultation of traditional native healers who may be unknowingly prolonging illness, rather than addressing and treating them due to lack of formal education and standardization of their treatments. The non-health nature of the mental health services in the country makes the situation more disturbing, as the traditional healers are essentially the mental health system. 

Traditionally, it is often thought that the elderly, women, and children are the most vulnerable groups to mental health issues in times of strife and hardships. As such, advocacy is regularly done to ensure that their mental well-being is taken into consideration as well as their special needs in times of personal or societal crisis.

However, more segments of the society are now quite susceptible to mental health challenges hence the need for timely interventions. From the long list of dissatisfied workers in work places, who regularly slip into depression without being diagnosed, unhappy spouses enduring their marriages or relationships, to hordes of frustrated and unemployed youths struggling to get by every day, the Nigerian society presents as a fertile ground for people to easily come down with mental health issues.

Gaping Gap In Nigeria’s Mental Healthcare Delivery
This, perhaps, underscores why statistics have it that over 60 million Nigerians suffer from mental illnesses. According to the President, Association of Psychiatrists in Nigeria (APN) and chairman, Faculty of Psychiatry, West African College of Physicians, Nigeria Chapter, Taiwo Obindo, “more than 60 million Nigerians are suffering from mental illnesses.”

“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 are unable to access care and this group is called the treatment gap for mental illnesses,” Obindo said.

The situation is made more grim by submissions by psychiatrists that around 11 people in a population of 100,000 die yearly by suicide in Africa, higher than the global average of nine per 100,000 people.

Medical Director, Federal Neuropsychiatric Hospital, Yaba, Lagos, Dr. Olugbenga A. Owoeye, on his part, explained that studies have shown that one out of every four persons has one diagnosable mental illness or the other, which is about 25 per cent of the population.

“So, you can see how common this condition is, mental illness is not only synonymous with those walking naked under the bridge; there are many people who dress very well and go to the office, but who are suffering from mental illness,” Owoeye said.

Owoeye shed light on some of the common mental illnesses in Nigeria: “They range from minor conditions to major ones. Minor conditions like stress-related disorders or acute stress reactions like generalised anxiety, and phobia of various types constitute the minor conditions. But when it is becoming major like in the case of effective disorders, major depression or in form of schizophrenia, it needs urgent attention.

“There are many types of schizophrenia. There is what we call a split mind; here, 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 conditions and this may be comorbid or coexisting with some other major mental illnesses. Other minor conditions include eating disorders like anorexia nervosa and bulimia nervosa,” he said.

Obindo observed that the gap in the nation’s mental healthcare was as a result of various factors such as the knowledge gap in which people do not have appropriate information about the causes and treatment for mental illnesses. He also listed some factors hindering the management of mental illness in Nigeria to include myths and traditional beliefs; inadequate mental health facilities and the required number of mental health professionals.

In Owoeye’s view, about 75 per cent of those who need mental health care do not have access to it, while for those who do, what they get is not qualitative mental health services.

“The only reason they are unable to access qualitative mental healthcare services is inadequate manpower. In Nigeria, as of today, we have about 300 psychiatrists to treat about 200 million people. The number of clinical psychologists we have is even lower. There is a scarcity of psychiatric nurses, social workers and occupational therapists and in spite the scarcity, these groups of people are still travelling out of the country in search of greener pastures.”

Owoeye also identified inadequate infrastructure as another challenge. He noted that out of 36 states and the Federal Capital Territory (FCT), the country has only nine federally-owned psychiatric hospitals, with six of them located in the six geo-political zones. He stressed that there is still need for more to cover all the states considering how common these conditions are.

According to Obindo, the few available mental health facilities in the country are located in city centres. “Knowing that 60 per cent of Nigerians live in the rural areas, they do not have access to appropriate care and have to travel long distances to access facilities.” He also noted that the number of mental health practitioners was low and falls below the ratio recommended by the World Health Organization (WHO).

The standard is that one psychiatric doctor should take care of 10,000 patients. But today, Nigeria is said to have one psychiatric doctor to more than one million Nigerians. “As we speak now, we have less than 250 certified psychiatric doctors throughout the country, and more are leaving by the day,” Obindo said.

According to him, the few that are trained are always eager to leave the country in search of improved remuneration and better work conditions. “The environment in which we practice, the security situation and the remuneration that people are given tend to push them out. There is always the pull factor from the developed countries where they tend to poach already trained medical practitioners in the country, particularly the psychiatrists,” he said.

Call For National Mental Health Policy
For Obindo, since the cost of hiring practitioners in low medium income countries remains low, it is always easier for developed countries to poach already made products rather than train such professionals locally, stressing the need for Nigeria to implement its Mental Health Policy on the practice of psychiatry. He said one major component of the policy was the integration of mental health into primary healthcare, which was yet to be achieved after almost 10 years.

Obindo added that the law operating in the country was the “lunacy act,” which was first enacted in 1916 and reviewed in 1958. “The Mental Health Bill by the mental health stakeholders, led by the Association of Psychiatrists of Nigeria (APN), in conjunction with the National Assembly and the Ministry of Health is yet to be assented to by the President. This is the most recent effort in 30 years,” he noted.

Stephanie Urigwe, in her review of Nigeria’s mental health policy, observed that it is geared toward forming a mental health system, but in actuality only a mental illness care system is the observed result of the policy.

“The government of Nigeria has drafted a mental health policy, yet its actual implementation into the Nigerian health infrastructure and society waits to be materialized. The limited health legislation or policy implementations tend to favour those who have access to urban areas and the facilities’ health services.”

Urigwe pointed out that Nigerians living in rural areas were at a disadvantage as many of them may not even be aware of services available to help them understand and treat mental illness. She canvassed that government-driven health interventions geared toward mental illness in rural areas would reach underserved Nigerians and Africans in general.

Urigwe said: “Issues with political instability and limited infrastructure often hinder crucial financial resources and legislation from reaching the people that are truly in need of governmental leadership in regards to mental health policy. Traditional healers are a severely untapped resource in the treatment of mental illness within the Nigerian population. They are abundant within Nigerian communities and are meeting a real need for the mentally ill. However, much can be done to remove the barriers that prevent the integration of traditional healers within the mental health system and improve the quality of care they administer within the population. Mental illness is almost exclusively coped with through traditional medicine practices. Mobilization and education from each stratum of Nigerian society and government as well as input from the medical community can improve how traditional medicine is utilized as a treatment for clinical illness and help alleviate the heavy burden of mental illness in Nigeria. Currently, there is no existing policy making structure for a working mental health system in Nigeria, and traditional healers are not taken into account in any formulation of mental health policy. Advocacy for mental illness is severely inadequate due to fear of stigmatization, with no formally recognized national or regional mental health association.”

Putting Government To Task
Obindo called for the passage of the national mental health bill as amended to ensure proper administration of mental health treatment, adequate funding, and remuneration of professionals. He said: “Mental healthcare should be incorporated into the primary healthcare system to cater to primary and secondary institutions treating mental health disorders in localities. Presently, the little budget meant for mental health treatment goes to tertiary medical institutions only. Mental health should be fully taken care of at primary healthcare centres.

“Percolating mental healthcare to primary healthcare institutions will save Nigerians transportation, feeding and accommodation costs, and the stress of conveying mentally-ill persons to urban centres where psychiatric hospitals could be found.”

Obindo also observed that Nigerians facing insecurity and forced displacements have continued to face psychological and psychiatric trauma and disorders. He therefore urged government to put in place programmes and initiatives to ensure that such people recover from the shock they have witnessed.

“It is important that governments and other support groups give them special attention to meet their current challenging emotional, psychological, and psychiatric needs so as not to fall into deeper depression or societal withdrawal,” he added.

WHO Regional Director for Africa, Dr Matshidiso Moeti, on his part, noted that 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.

“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,” he noted.

WHO added that, in Africa, underinvestment by governments is the greatest challenge to adequate mental health service provision. It noted: “On average, governments allocate less than 50 U.S. cents per capita to mental health. Although it is an improvement from 10 U.S. cents in 2017, it is still well below the recommended U.S.$ 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.”