Improving access to mental health via primary care

It is not news that the majority of those with mental health problems in Nigeria do not seek the care they need from mental health care facilities. They are more likely to be in denial initially and refuse to agree that there is a problem. When they eventually come around to agreeing that a problem exists, it is often more acceptable to label the problem a spiritual attack and so head to the church, mosque or traditional healers.

Nollywood perpetuates this myth by portraying hospitals as places where the mentally ill are often advised to leave and seek alternative care because they are helpless and cannot offer any treatment. But we know this narrative is false and misleading.

Mental illnesses are simply disorders of brain functioning, as a result of abnormal levels of brain chemicals. Treatment usually involves drugs that correct these imbalances and the individual will recover and get well.

Nonetheless, the facts on the ground indicate that the majority of psychiatric services are only available at tertiary facilities – the Neuropsychiatric facilities such as Aro in Abeokuta and Yaba in Lagos; as well as Departments of Psychiatry in Teaching Hospitals and Federal Medical Centres.

Several people are reluctant to go to these facilities on account of stigma until they are so sick that they or their family members no longer care. Mental health care services are practically non-existent at secondary and primary care levels across the country.

This situation has ensured that even when people wish to access qualitative mental health care services, it is often not readily available. This is described as treatment gap. For example, if 10 people are suffering from depression and only three of them are able to receive treatment, the treatment gap for depression will be 70 per cent (i.e. seven out of 10 people did not get the treatment they needed).

A series of world mental health surveys conducted by the WHO in several countries including Nigeria, indicated that the treatment gap for mental health problems in Nigeria was 80 per cent. This means that eight out of every 10 Nigerians with mental health problems are not getting any treatment. What is the way forward to resolve this unacceptably high level of treatment gap?

The solution can be found in the foresight and wisdom of the late former Minister of Health, Professor Olikoye Ransome Kuti, who ensured that mental health was included as the nineth component of primary care, and a mental health policy was drawn up in 1991. This was to ensure that mental health services are readily available, accessible and affordable within the community.

But unfortunately, very little has been done in this regard over the years. The WHO tool for training primary care workers in mental health (mhGAP Manual) has been adapted for Nigeria and successfully piloted in Osun State by Professor Oye Gureje and his team.

Lagos State is now leading the way with respect to successfully integrating mental health into primary care across the entire state. This is the first state to appoint a Mental Health Desk Officer for Mental Health.

Furthermore, the Mental Health in Primary Care – Transition to Scale (MeHPric-T) Team, led by Professor Biodun Adewuya from LASUCOM are spear-heading this project, with the active support and collaboration of the Lagos State Ministry of Health and the State Primary Health Care Board.

The Project is funded by the Grand Challenges Canada, but the state government is committed to its sustainability and is gradually taking ownership of this initiative. This is certainly the way to go, and provides a template for other states to emulate.

Benue State and the Comprehensive Community Mental Health Programme (CCMHP) of the Methodist Church, which is funded by CBM and Australian Aid is also engaged in rolling out a community and primary care based mental health care services. They have also appointed a Desk Officer for Mental Health, to claim the silver medal, behind Lagos State.

Oyo State is also working hard, and the new Commissioner for Health, Dr Azeez Adeduntan has been very proactive in his reforms, as well as support for the Professor Oye Gureje led efforts to integrate mental health into primary care in the state. He has promised to appoint a designated Mental Health Desk Officer very soon. If this is implemented, then Oyo State would clinch the bronze medal at this point.

Ultimately, the successful integration of mental health into primary care should translate into a reduction in treatment gap as well as improved access to good quality mental health care services.