How native doctor impregnated girl to heal her of mental illness —Psychiatrist, Dr Abdulmalik
•‘Nigeria still operates 62-year-old law to protect persons with mental health challenges’
Dr Jibril Abdulmalik, a consultant psychiatrist and senior lecturer at the Department of Psychiatry, College of Medicine, University of Ibadan, speaks to SADE OGUNTOLA on mental health problems, their management and the inherent challenges in Nigeria.
What really is mental illness?
Mental illness is a health condition that involves changes in our thinking, emotions and behavior. Sometimes it is a combination of these. There could be an abnormality in behaviour, thinking and emotions and usually these changes have associated problems with functioning in day-to-day living, at work, in the family and it makes it clear that something is not right.
Our brain controls all of these functions. So, when we talk about mental illness, it is a disorder of the brain that involves an abnormality in our thinking, emotions, and behavior; that affects our day-to-day functioning in the family, at work and in the other spheres of our lives.
Is there a particular case you consider as the most pathetic of all cases you have handled in your career?
Well, unfortunately, for the practice of psychiatry, you see so many pathetic cases most of the time, especially where the family members are not supportive; where they abandon the individual. In fact, you will find that most of those roaming the streets are individuals who have been abandoned by their relations.
But if I were to pick one which I feel is the most pathetic that I have personally seen, it was the case of a young lady, an undergraduate, who had severe depression and was also hearing voices and seeing things. Her parents took her from school and believed that it was spiritual. They took her to somewhere for traditional/spiritual treatment where she was chained and abandoned. Of course, they were visiting her. But after several months, it became clear that the traditional healer looking after her had impregnated her and the pregnancy was already advanced. The parents were very upset. The traditional healer said only he could subdue the demons possessing her and that the solution was for him to marry her as his third, or fourth, wife.
Of course, the parents were very upset. They took her from there, but they didn’t arrest the man because they were the ones that took her there in the first place. The case was settled amicably but the girl never returned to school. She had that baby and eventually, she went to learn tailoring and this was someone who was so brilliant. She is scarred for life. It was after that episode that they brought her to the hospital and we tried to encourage the family to let her return to school, that it was not too late. After a while, she stopped coming to the hospital and when we followed up, the last we heard was that she had been married off to somebody else and she was doing tailoring.
That was a case that really struck me as a waste of talent and brilliance simply because of wrong choices and wrong decisions. There are so many cases like that all over the country. This is why we are embarking on this awareness. This is why the ASIDO Foundation is trying to create awareness on mental illnesses and this is why we are calling on everybody to make sure that we spread the information that mental illnesses are just like other chronic illnesses and that they can be treated.
The age when it happens is when they are in school; they can be treated and they will recover. They can live successfully; they can achieve their full potential without any problem. In fact, children are being withdrawn from school because they have epilepsy. Children are being withdrawn from school because they are hyperactive and restless, conditions that can be very easily treated in the hospital and they will recover and go on with their education and realise their potential.
These are the major problems that we have and I think that the biggest obstacles that we need to surmount are ignorance, superstitious beliefs as well as shame and stigma. And this all what the ASIDO Foundation is trying to push back so that when there is more understanding and no more shame and stigma, people will come forward freely when they need treatment.
There is a general belief that mental illness is spiritual and is incurable. How true is this?
That is not correct. Mental illness is a disease of the brain and because we understand the way the brain works, we also know what goes wrong when there is mental illness. So, we have treatment in terms of drugs and other modalities that we can use to correct what has gone wrong.
It is just like saying that malaria is caused by a spiritual problem when we all know that if you have malaria, if you do a malaria test and it is positive, you take antimalarial medication and you will recover. Similarly, for mental illness, we know that abnormal levels of certain chemicals in the brain cause these abnormalities of thinking, emotions and so on. And when we use drugs that correct these chemical abnormalities, people recover and they are fine and they live their normal lives and keep moving forward.
Does it, therefore, mean that every mental illness is curable?
Let’s make a clarification between cure and management. We only talk of cure when we are talking of some infectious conditions like malaria. If you have malaria today and you take malaria medication, after one week, if you take a malaria parasite test, it is no longer there. You know that you are cured but that does not mean that you cannot be infected again at some point down the line.
But for conditions that we call non-communicable diseases, which are not infections, like hypertension, diabetes, sickle cell disease, we don’t talk about curing these conditions. We talk about managing and controlling them with medication, regular follow up and lifestyle changes.
Mental illnesses, too, are non-communicable because they are non-infections. So, we don’t talk about curing them, we talk about managing and controlling them with medications and lifestyle changes and individuals with these illnesses will be fine just like somebody with diabetes that is well controlled, or somebody with hypertension that is well controlled, or somebody with sickle cell disease that is well controlled and is not having a frequent crisis. Somebody with mental illness, too, can be well-controlled with medications and regular checkups. Such a person can also be 100 per cent fine and live their normal life without any problem.
There is a popular saying that everyone experiences five minutes of madness every day. Is this true?
That is not true. It is a myth that has become popular over time that everybody has five minutes of madness. That is not correct because that presupposes that everybody runs mad at some point or has a mental health problem. People may lose control, they may get angry and maybe upset but that is not mental illness because the criteria we use for determining metal illness are specific.
There are three things that must take place before mental illness can be established. The symptoms must be very severe, it must last for a long period and it must cause impairment in day-to-day functioning. It must prevent them from functioning normally.
For instance, everybody has good days and bad days. But if you wake up and you are not good today, it does not mean that you are depressed or have mental health. You may say ‘I am sad’, ‘I am not happy today’, but that does not mean that you are depressed. But if you feel excessively sad that you are miserable and crying all the time; you don’t feel like doing anything, then that is severity. These symptoms that are so severe last for several weeks and then duration as a condition for mental illness is fulfilled.
The third one has to do with impairment of functioning. If all of these symptoms that are so severe and are lasting for so long are preventing you from concentrating on your job, from relating with your family, from being focused as a student, from studying, from going to class and so on, then you have met the three criteria that establish that there is a mental health problem that requires intervention.
So, when you look at it that way, it is not possible for an individual to have five minutes of mental illness or five minutes of madness every day because it wouldn’t be severe, it wouldn’t have lasted long, it would not have affected day-to-day functioning. It will just be like mood swing or anger. That is not mental illness.
Are there particular causes or predisposing factors to mental illnesses?
The best way to look at this is to remember that mental illnesses are not stand-alone; they are part of a family of non-communicable diseases. Like hypertension or diabetes, one risk factor is family history. But it is not automatic that if your parent has hypertension, diabetes or mental illness, you must have these diseases, it just means that you have a higher risk than somebody whose parents do not have it. Also, there are biological risk factors, including family history. Psychological risk factors also increase the chances of developing a mental health problem. These include traumatic childhood experiences like bullying, and low self-esteem. Then there are social risk factors that include dysfunctional family, broken homes and difficult life circumstances.
But just like hypertension and diabetes, you cannot put your finger on one thing and say that this one thing is the cause, likewise in mental health, just like other non-communicable diseases, it is not that straightforward. It is a combination of these factors acting together in somebody that has a vulnerability that will now lead to the manifestation of mental illness.
Can other health issues lead to mental illness?
Absolutely. The World Health Organisation defines health as a state of complete physical, mental and social wellbeing. So, there are three components to health. Now, all these components can lead to mental health issues. For instance, a man that became paralyzed following a spinal cord injury he sustained in a road accident wouldn’t be happy. The chances that he will develop depression will be very high. It will not be surprising that someone diagnosed with cancer and told he had six months to live may become depressed, likewise a woman having difficulty achieving pregnancy. All these are physical health issues that may cause mental health problems.
Social issues can also cause a mental health problem. If an individual in an unhappy marriage where one is beating the other every day, the chances that the battered spouse may become depressed becomes high. So, social and physical health problems can increase the chances of developing a mental problem. They may even be the starting point of a mental health problem.
How affordable is treatment for mental health conditions?
It is very affordable. One of the most severe types of mental illness is called schizophrenia or psychotic illness where a person is hearing voices and behaving abnormally. The medications that they will require on a monthly basis are not up to N5,000. In fact, between N3,000 and N5,000 will take care of the medications required for most mental disorders in a month. These medications are far cheaper than medications for other non-communicable diseases such as hypertension and diabetes. So, it is very affordable.
In fact, what I tell people is that most times when they go to traditional healers and all other places where they go to, they end up spending more. The cost of the items that they will ask for at the end of the day will be high. It is like an indirect payment system that they use, which is actually more costly and less effective than bringing them to hospital for treatment.
The society tends to stigmatise persons with mental health challenges. What would be your advice on this?
This is the biggest challenge we face when it comes to mental health or psychiatry in Nigeria. Ignorance, stigmatisation, shame and all of these issues arise from misconceptions and lack of understanding of mental illness. Some people, because they think that it is a spiritual problem, want to run away from it. They don’t want to go near someone who has it.
Family members of somebody who is suffering from a mental health problem are embarrassed and so they hide the person away; they abandon them, they take the person to the village or lock them in the house. This is just not fair. The question we should ask ourselves is: if we were the ones in that situation, would we want to be treated that way? Sometimes in the places where they take them to, they chain them. Sometimes they beat them, deny them food, the women are sexually abused and so on. These inhuman practices they are made to pass through continue to be a big problem in our society.
You coordinate a non-governmental organisation that focuses on mental health. What informed its establishment and how is it faring?
The ASIDO Foundation, as it is called, was established last year to tackle the biggest problems we have in mental health. These are ignorance, lack of understanding, lack of awareness about mental illness and issues around them. I am especially grateful to the Nigerian Tribune for providing the platform for a weekly column titled ‘Your Mental health and You’ since 2016 though which we have been trying to explain what mental health is all about to the reading public.
However, we have realised that we need to do much more to take this information to the communities using every possible means. What the ASIDO Foundation is trying to do is to promote better understanding of mental illness, to reduce the associated shame and stigma and to encourage people who are affected to come forward and seek treatment so that they can get well and return to their normal life. This we have been doing for a year now.
We clocked one on 1 August, 2020, and we think that, to a large extent, the awareness is increasing across the country. Many people make use of our toll-free line to speak to mental health professionals – psychiatrists, clinical psychologists and psychiatrist nurses – across the country. When people call our helpline, we call them using our own airtime to discuss with them and find out what their problems are. If it is something we can handle straightaway, we do so. And if it is one that requires that we refer them to the nearest hospital, we do that as well. When we marked our first anniversary on August 1, we launched a new campaign called ‘Unashamed2020’ and the aim is to reduce the stigma associated with mental illness in our society, especially because this is the year 2020 – we are starting a new decade.
We want the new decade to be a new chapter in the history of our country where there is open conversation; no more shame; no more stigma and inhuman treatment of persons affected by mental illness. This is what the ‘Unashamed2020’ campaign is all about. And we encourage everybody and we are hoping that we will get one million people to go to our website, www.asidofoundation.com/unashamed2020 and to take the ‘unashamed’ pledge. It is a pledge to support people with mental illness, a pledge not to discriminate and so on. These are positive affirmations. They put their names there and they sign the pledge.
We are hoping to get a million people who will take that pledge within the next one year. At the moment, we have just about 2,000 people that have taken the pledge. We still have a long way to go but we are hoping that more Nigerians will embrace this call, support it and go to the website to take the pledge and encourage their families and friends to take the pledge so that we all become more aware of what is going on and how to support and encourage people who are affected.
Nigeria has a law on mental health, why are you not tapping into that to ensure an end to these challenges faced by people with mental illness?
It is unfortunate that the law currently regulating mental health practice in the country is an obsolete, ancient law that we inherited from the colonial masters. It is called the Lunacy Act of 1958. Even the name is something one is embarrassed to say publicly, the Lunacy Act, because if I am depressed, I wouldn’t want you to refer to me as a lunatic because I have depression. If I have anxiety or my wife is pregnant and she has postpartum depression, I wouldn’t want you to refer to her as a lunatic. Of course, medical practice and psychiatrist practice have evolved since almost 70 years ago. So, that is like a 62-year-old law. You can imagine all the advancements that have taken place.
Fortunately, there is a glimmer of hope. The National Assembly, through the chairman of the Senate Committee on Health, Senator Dr Ibrahim Oloriegbe, is sponsoring a new mental health bill that has gone through three readings. The committee had a public hearing in February before the COVID-19 pandemic came about.
We are hoping that this bill will be followed up. What is outstanding are just a few technical inputs from all stakeholders, some corrections and editing and we hope that finally, this new mental health bill that is in line with global health practice, that promotes and upholds the fundamental human rights of persons who are affected by mental illness problems, will finally be passed and will be signed into law by the president. That will protect them from abuse and guide the practice of everybody who is caring for people with mental health challenges so that we can at least come of age in terms of having a modern mental health law that is in tandem with global best practices.
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