Mental Health Care in Nigeria; the forgotten issue

Another traffic jam in Lagos. A ‘madman’, tattered and unkempt, strolls casually to a couple in a black jeep. With little ceremony, he extends his arms and demands money. The couple look straight ahead and ignore his request, the driver moves the car forward slightly.

The madman follows them, this time pounding against the glass and threatening to break the window. Still they attempt to drive on, failing to acknowledge him. He retreats as the traffic begins to pick up and the couple heave a huge sigh of relief.

Hundreds of cars pass and no reports are made to the police nor to any mental health authorities. Weeks later, the ‘madman’ is still there, still demanding money.

Stigma

Mental health problems remain a huge stigma in Nigeria with most people, even families of victims, choosing to ignore them in the hope that the problems will simply go away.

The problems, however, rarely vanish and whether an individual’s problem is severe or mild, if not treated, it can result in exclusion from society, loss of work, and breakdown in relationships. Families usually struggle to find help, but in Nigeria today, that search is often in vain.

The result of this is that many people are suffering unnecessarily, and in the worst cases are subjected to being chained, beaten and subjected to terrible abuse, sometimes at the hands of those who they have turned to for treatment.

In spite of highly effective and affordable treatments which have become more readily available, Nigerian citizens are still not fully benefitting.

Lazarus Nwajei, whose wife suffers from schizophrenia, says mental illnesses still attract shame to many families in Nigeria.

“My wife’s mental illness started after the birth of our fourth child in 1993,” he says. “At first I thought it was high fever but when it degenerated to the point of her making trouble with everybody in the neighbourhood and going nude at times.

“It has been hard for us, especially me, the husband, because of the costs, work and shame that I have to bear.”

Mercy Agbedion, complains that treatment is expensive for her brother, Leonard, because the drugs are still so scarce.

“My elder brother’s mental illness started about 10 years ago at Lokoja, when he was working there,” she says. “Since then it has not been easy for us his family members. We have learnt to live with the stigma of being related to a mad man but the fact is that his illness is eating deep into our purse.”

Mercy, like so many other relatives living with mental health, exhibits little faith in Nigeria’s mental health institutions and sees little point in taking her brother to a psychiatric ward.

“We refused admitting him in a psychiatric hospital because we believe he will be better with us than keeping him in the midst of other mentally derailed persons.”

Nigerians have not always been so faithless when it comes to dealing with mental illness.

A proud history

Prior to the colonial era, there were healers in all the various ethnic groups in Nigeria, whose expertise was the treatment of mental health problems.

The fathers of modern psychiatry in Nigeria trained in Britain in the 1950s and on their return, set about transforming the few colonial-era asylums in the country.

The first indigenous Nigerian psychiatric professional was a psychiatric nurse, Mr Abraham Ordia. He was the first Nigerian to hold a senior position in what was then called the Asylum at Yaba in 1952.

The first Nigerian doctor specialising in mental health as a Psychiatrist, was the late Professor Thomas Adeoye Lambo. He was trained in Britain, and returned to Nigeria in 1954, making an international name for himself in Aro Hospital, Abeokuta with his renowned Village System of care.

He realised that people who are taken away from their home communities to be treated actually find it harder to be independent when they go home than those who receive care in the community.

This era also saw a revolution in medical treatment for mental illnesses. It was only with the discovery of effective medication in the 1950s that the most severe symptoms could be effectively controlled.

Even people with very disturbed behaviour could recover and return to their communities.

Sadly, the system in Nigeria has not kept up with these early advances. Recent studies based in Nigeria have shown that only around 10% of people with severe mental illness receive the care they need.

The specialist hospitals in big cities like Lagos, Ibadan, Enugu, Calabar and Sokoto are not sufficient to provide care that is affordable and accessible by the majority of the population that needs it.

Lack of human and financial resources

Nigeria only has about 130 specialist psychiatrists, less than one per million of the population compared to a typical figure in European countries of one per 10,000 people. There are more Nigerian psychiatrists in Britain alone than in Nigeria.

We are slightly better served with psychiatric nurses, who would form the basis of a primary health-care based service. Nigeria in fact trains significant numbers of these essential staff, though many are also lost to the brain drain.

In Nigeria less than 3% of Gross Domestic Product (GDP) is spent on health, and of this less than 1% is allocated to mental health.

The figure recommended by the WHO for mental health is 5%, and in many countries it is nearer 15% The low level of expenditure means that even if services were well organised, the majority of cases could not receive the care they need.

The most severe mental illnesses require long-term treatment. Although this treatment when given in the community is not expensive, the system of paying out-of-pocket means that many families find it hard to afford the care their loved ones need month after month.

It is unclear whether the National Health Insurance Scheme will adequately cover mental ill health.

Policy and legislation

In Africa overall, less than 50% of countries have a mental health policy. In Nigeria, the progressive 1991 primary health care policy states that mental health should be integrated at the primary care level.

In response to the international priority being given to mental health, there are now plans to update Nigeria’s legislation.

At present, the existing legislation dates back to British colonial laws of 1916, later adopted as the Lunacy Act in 1958. The legislative process has not responded effectively to the need for radical reform of the sector.

A 2003 bill for a mental health act passed a public hearing and was adopted by the Senate, but was not able to pass the House of Representatives and be adopted into law before the end of the last administration.

With support from the WHO, the Federal Ministry of Health has brought together a team of experts to make recommendations for laws that will safeguard the interests of people with mental health problems in the country, and a policy that will allow for services to reach those whose needs are currently not met.

If these plans are to be implemented, significantly higher levels of resources will need to be devoted to this neglected area.