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Why accessible, affordable treatment is vital to curbing rising mental health challenge 

By  Eno-Abasi Sunday, Tobi Awodipe, Paul Adunwoke (Lagos) and Murtala Adewale (Kano)
10 October 2021   |   3:06 am
At the birth of the World Federation For Mental Health (WEMH) in 1948, the world was still struggling to come to terms with the post-World War 2 realities.

Osagie Ehanire

At the birth of the World Federation For Mental Health (WEMH) in 1948, the world was still struggling to come to terms with the post-World War 2 realities. 
 
Emerging from that war, there was the compelling need to jointly tackle the humanitarian crisis that had engulfed the world, and the collaboration between the WFMH, the United Nations (UN), the United Nations Educational, Scientific and Cultural Organisation (UNESCO), the World Health Organisation (WHO) and sundry international stakeholders that have interest in mental health wellbeing provided the needed balm.

 
This time around, the world has found itself in yet another global crisis, – the Coronavirus Disease (COVID-19), which has not only smothered millions of lives but has put health infrastructure in many countries under duress, heightened economic and social challenges and generated widespread inequalities in diverse areas of human life.
 
Expectedly, in such an atmosphere, so many things are bound to go wrong if the impact of the pandemic is not well managed through conscious policies. Indeed, if not properly addressed, the fallouts could include increased inequalities, widespread global unemployment, deaths, medium and long-term discrimination, as well as, mental health challenges among others. 
 
In a country where healthcare has already been seriously challenged for decades, occasioned by the dearth of infrastructure and shortage of manpower, the mental health of its inhabitants is bound to take a serious hit.
 
Before the pandemic, the WHO had earlier alerted that one in four Nigerians suffered from some sort of mental illness.

As the world marks the 2021 World Mental Health Day today, Nigeria is still nowhere near being equipped to solve prevailing mental health challenges. With just about 250 psychiatrists in the country and only one out of 10 people with mental health problems able to access quality care, the dearth of mental health nurses, clinical psychologists, and social workers have compounded the national mental health challenge. 

It is in the light of rising economic hardship that experts are urging Nigerians to worry less and seek immediate medical attention to avoid precarious condition. They also want the government to close the 90 per cent treatment gap to avert wider repercussions in society.

In assessing the mental health situation of Nigerians, and how much of a challenge it poses to the country’s wellbeing, Dr. Tunde Ojo, a mental health specialist with experience in mental health promotion, prevention and management of mental health conditions using psychotherapy, counseling and pharmacotherapy amongst others regretted that the mental health situation of Nigerians is “far from being taken care of.”

His views are shared by Dr. Oluwatosin Helen Kadri, of the Department of Psychiatry, Lagos University Teaching Hospital (LUTH), who insists that besides mental health being neglected in this part of the world, the disparity between available healthcare services and the need for mental health services is palpable. Although the country has made significant advances on challenging public health problems, health-related policy development and legislation in trying to achieve health for all, there have been challenges with regards to mental health services, including that of policy development and legislation, financing, research, training and the integration of mental health care into primary health system.

Ojo, a consultant psychiatrist and Head of Department of Mental Health, University of Abuja Teaching Hospital continued: “We can’t say that people’s mental health is being prioritised, or taken care of when the treatment gap is over 90 per cent. This means that for every 10 people with mental health problems in the country, just one can access quality care. We cannot also say mental health is being taken care of when there is no human resource or financial resource available; only a handful of mental health treatment services around the country and even the few available are concentrated in major cities, whereas most of the people who require mental health care are resident in the rural areas. 

 
“We cannot also be talking of a good mental health system where you have very few health professionals to take care of millions of people. If you look at the number of psychiatrists in Nigeria, it is pathetic – about 250 only. It is even worse when you look at other health workers in this field, such as mental health nurses, clinical psychologists and social workers, their numbers are even more dismal, and it is dwindling daily as qualified personnel are leaving. A lot needs to be done in the area of mental health services development in Nigeria, as you’ll notice that most of the focus around mental health in Nigeria is centred on treatment. This is a wrong approach. Mental health isn’t just about treatment; it should be more about mental wellbeing and promoting good habits, as well as the prevention of mental health issues. When you have a situation such as ours where our mental health needs are not addressed, it hurts the country’s wellbeing, starting from the individual level. A healthy nation is a wealthy nation and Nigeria is sadly not investing in mental health. There cannot be general good health without sound mental health and we need to invest more in health to have more money. When you have a healthy population, the development would be rapid, so if more investment is put in health and mental health, our productivity as a country will increase significantly.”
 
He, however, expressed dissatisfaction at the level of attention given to the malaise by the government, especially given its impact on productivity and nation-building.
 
Ojo explained: “It is not possible to be satisfied with the level of attention that the government is giving to mental health presently; ordinary Nigerians are unhappy, just as experts are. What the government is barely trying to provide now is treatment, which is wholly inadequate as there is a 90 per cent treatment gap. This is very poor. So, the government needs to do more and if attention isn’t given to mental health, it would have bigger repercussions.”
  
On why mental health issues are not taken seriously by Nigerians even though caseloads appear to be rising, Ojo explained: “Policymakers and government’s lack of political will is not helping matters because where there is a will, there is a way. Therefore, even if there were to be abundant resources and no political will, nothing will get done. With scarce resources and political will, there are always innovative ways of getting things done. To be fair to the government, disposable resources are scarce, but it is clear that we need to allocate more resources to the health sector in general and mental health specifically. Of the budgetary allocation given to health yearly, mental health services get less than three per cent, and of this dismal figure, over 90 per cent of it goes towards hospital-based care. This is just the tip of the iceberg on what needs to be addressed regarding mental health care. 
 
“Another major obstacle is ignorance as most policymakers are not aware of the central role that mental health plays in productivity, hence the poor attention that it is getting. Again, if you don’t have a policy or a policy backed by legislation, it is as useless as a barking dog that cannot attack. However, thankfully, the present National Assembly has passed a Mental Health Bill that is awaiting the president’s assent and I believe this would change a lot of things in the mental health landscape.
 
On the part of Nigerians, the biggest treatment gap remains a stigma. People know where to get mental help and can sometimes even afford it but refuse to because they don’t want to be stigmatised for admitting that they have a problem. People with mental health problems are also discriminated against everywhere, and this becomes almost like a death sentence for them even to the point that they refuse to access care. We need to address stigma towards people living with mental health problems.
 
Another challenge that helps in worsening an individual’s mental situation is that some affected persons may not know that they are challenged hence the need to seek medical attention.
 
While admitting that the list of what to look out for before seeking professional help is in-exhaustive, the mental health specialist added that “for most people, the problems are usually insidious at the onset, and it is people around them that notice it first. However, things to look out for include insomnia; change in behaviour; reduced socialisation; withdrawing from people and activities previously enjoyed; feeling weak most times; persistent unusual sadness that goes on for long; feeling low, hopeless or helpless; questioning one’s existence; suicidal thoughts; loss of appetite/weight; not meeting deadlines at work and so on.
 
Beyond these common signs, others include, becoming unusually suspicious of people; hearing voices or seeing things that others cannot see, and a decline in personal hygiene. Once these signs are manifest, affected persons should be taken seriously. Most people try to cope with their symptoms because of stigma because they don’t know how people around them would react. 

He described unemployment as an associated factor that has led to increased use of psychoactive substances, stressing that most unemployed people are more likely to get involved in crime. Most criminal activities these days are mostly drug-fuelled, but unemployment isn’t the only factor responsible for increased drug use in Nigeria today. The drug epidemic as we have it now is more among the young because this is the period they experiment and try to define who they are, coupled with peer pressure and a need to belong. Most started using drugs to experiment socially, get hooked and it snowballs into a major problem for them, leading to criminality.

“People with mental health issues are more likely to be unemployed and dependent on their relatives. If Universal Health Coverage (UHC) can be expanded to include mental health, people wouldn’t have to resort to out-of-pocket expenditure, which can be catastrophic financially.
   
The consultant psychiatrist further stressed that addressing the treatment gap would require producing more psychiatrists, clinical health psychologists, psychiatric nurses etc. “But no matter how many we produce, which we, unfortunately, are not producing, they will never be enough. We have the highest caseload of depression in Africa. The WHO recommends one doctor to, at most, 600 patients, but in Nigeria, one doctor sees over 6, 000 patients with the number of patients climbing daily as more doctors leave and mental health cases rise. The solution to this treatment gap is to look for more innovative ways to address this problem such as taking mental health services closer to the people. Presently, there are just eight neuro-psychiatric hospitals in the country, and some teaching hospitals have psychiatric departments, but these cannot take care of the mental health needs of 200 million people. It’s sad, but the truth is that most people that need mental health services would never be able to access it in their lifetime while others that can have to travel hundreds of kilometres and spend a lot to get it. Mental health services must be accessible, affordable, available and qualitative. We should have community mental health services by activating the mental health component of primary health care because it is a key component of primary health care services.

“Beyond integrating mental health care services into primary health care and other existing platforms, clinical psychologists and psychiatrists cannot be everywhere so PHC workers can be trained to identify, and even treat common mental health problems. The ones they cannot take care of can be referred to specialists, he added. 

  
“Health insurance is a good way to addressing some of the gaps in mental health treatment, just as there is also need to be a paradigm shift from treatment to prevention and promotion. This can be done by demystifying mental health by making it a part of school’s curriculum and teaching people how to increase their mental health resilience; all these can reduce treatment gaps and should be put into consideration,” said Ojo.
  
While urging Nigerians to “take care of their mental health now more than ever, and be more mentally aware, and realistic in their expectations,” he cautioned against going into unnecessary debts or making unrealistic plans. If you try to live above your means, it would affect your mental wellbeing significantly. Starting new businesses with loans should be avoided because if it fails, you can have a mental breakdown. Take care of your mental health, sleep well, reduce stress as much as possible, exercise, and eat good food and fruits within your means too. In times of uncertainty like this, the government should provide safety nets for people like social investment programmes where people can access funds and resources and enable Nigerians to get back on their feet and restart their lives.
 
Commenting on the theme for this year’s celebration, which is “Mental Health in an Unequal World,” and the extent to which the COVID-19 pandemic and the resulting economic uncertainty worsened the mental health of Nigerians, Ojo said: “Looking at this year’s theme, it is very apt because we live in an unequal world and the more unequal the world is, the more mental health challenges we will have. So, what we have now is places where mental health services are available but inaccessible or unaffordable to those who need them; this is the inequality we speak of. Countries that have more resources tend to invest more in their people’s health-giving rise to increased productivity while those that don’t have cannot invest in basic infrastructure nor can they invest in healthcare. Linking this to the Sustainable Development Goals (SDG), it’s clear that we can’t talk about health in isolation; our environment, infrastructure and gender issues all affect our health. 
  
“In an unequal world where there is gender discrimination and gender-based violence, women’s mental health is more impacted negatively. Because we’re in an unequal world, poorer people with mental health issues cannot afford treatment and would have to resort to places where they cannot get help, ignoring places that would give them the necessary help they need. Therefore, this year’s theme of addressing mental health challenges in an unequal world shouldn’t just be about service provision but reducing inequality, advocating for inclusive development, advocating for better treatment for mental health patients; because if these set of people are not included in our developmental plans, we are disenfranchising them and it would hurt their mental health…During the lockdown last year, many people’s mental health was affected leading to a spike in depression, anxiety and post-traumatic stress disorders. There is also a strong link between mental wellbeing and income/poverty status. After the lockdown last year, many people lost their jobs and we witnessed an increased use of substance usage and alcohol because people were wrongly using these as a means to treat isolation and depression. We also saw a rise in Intimate Partner Violence (IPV) and Sexual and Gender-Based Violence (SGBV). During that period, many with mental health issues couldn’t access their regular care and therefore relapsed, worsening treatment outcomes in them. 
  
Like Ojo, Kadri who admitted that the country’s mental health gap was further worsened by COVID-19, however, informed that the Global Burden of Diseases, Injuries, and Risk Factors Study, equally pointed out that mental illnesses of various severity impacted Nigerians even before COVID-19. This amounted to millions of persons with mental disorders in the country. 
   
She regretted that most Nigerians have a superficial perception of mental health with the majority considering mental disorders as physical manifestations of violence and extreme irrational behaviour. They less understand it as a mental condition that may affect only the mood or an individual. Or the thinking process and behaviour of a person. This uneducated outlook poses the first and major barrier to diagnosis and therapy.

Another reason why mental health issues are not taken seriously is that it’s being spiritualised, seen as a nemesis, or punishment for one’s sin.

Our culture also has a role to play in this.”

  
Also enumerating factors that impair treatment, she said the lack of understanding of the root causes of mental illness; lack of financial support to get mental treatment; lack of social support (family, friends, neighbours); the fear of stigmatisation concerning being labelled as mentally ill, or being in association with the mentally ill, 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 standardisation of their treatments. 
  
“Data from the WHO captures the grim state of our mental health as Nigeria has Africa’s highest caseload of depression and ranks 15 in the frequency of suicide in the world.”
  
She also lamented that if the available 250 psychiatrists are spread evenly over the 45 mental health facilities to treat the 50 million afflicted with mental ailments, each facility will have six psychiatrists to attend to at least 1.1 million waiting patients. This shortage of mental health personnel is the second limitation against anyone who struggles with some mental condition in Nigeria.
  
The scarcity of psychiatrists is a corollary of the gross shortage in the number of facilities for them to practice. Going by the huge costs of qualifying as a specialist in psychiatry, no one wants to graduate with little or no place for them to work.
   
But despite ranking 15 in the frequency of suicide in the world, a consultant psychiatrist at the Aminu Kano Teaching Hospital, Kano, Dr Aminu Shehu Ibrahim, said that effective management of mental health conditions would reduce 90 per cent of suicide cases in the country. 
  
Said he: “Although Nigeria lacks accurate data to give actual statistics of people suffering from mental health, the daily reports of suicide speak volumes of the situation. Also, the cases we see in the hospital indicate an increase in suicide cases. 
  
“And, again it might not be difficult to resolve or imagine such situations considering the economic realities in the country, coupled with the fact that people hardly seek mental help due to their economic situation etc.
  
“Besides, we don’t have enough manpower to manage mental disorders in the country. We have a limited number of psychiatric doctors; the ratio is around one doctor to 800, 000 patients. This is grossly inadequate,” he said. 
  
For the past President, Association of Resident Doctors (ARD), Federal Neuro-psychiatric Hospital, (FNPH), Yaba, Lagos, since a high number of those affected by mental ailments “are youths who constitute the backbone and strength of the productive economy in any nation,” the government must do so much more to improve the situation. 
  
“It is also imperative to mention that we have inadequate mental health experts. Psychiatrists, pharmacists, psychologists, nurses, social workers, occupational therapists who make the mental health team are not enough to meet the number of Nigerians who need their services. This has become worse in the last one year due to the mass migration of these specialists to other countries for better remuneration, improved social welfare and ideal healthcare services delivery conditions.”