Nigeria has fewer than 300 psychiatrists for its over 200 million population — Obindo, APN president

The president, Association of Psychiatrists in Nigeria (APN), Professor James Obindo, in this interview with SADE OGUNTOLA x-rays challenges to maintaining good mental health among Nigerians and what needs to be done.

Mental health in Nigeria appears to be a neglected public health issue. What’s your take on this?

Yes, mental health has been neglected. People with mental health issues are neglected. The profession itself is neglected while emphasis and significant budgetary allocations are given to other aspects of public health like HIV, malaria and cancer. If you look at the government’s meagre allocations to health, only a little of it eventually trickles to mental health and mental health issues. In the Federal Ministry of Health, until a few years back, we did not have even a mental health desk officer. How then do you think mental health issues can be pushed?

The law governing mental health in this country is still largely the Lunacy Act promulgated in 1907, which looks at mental illness as an aberration and a disturbance even to the society, and therefore those who have mental illnesses are meant to be kept away or locked up in an asylum, without care, without plans for them. The mental health policy that was first passed in 1991 and revised in 2013 is just gathering dust on the shelf and is not implemented thus far. Thus, we can see the neglect and lack of priority for mental health.

How will you rate the mental health of Nigerians and what are the predominant mental health conditions in the different gender and age groups?

I will say this is poor and needs urgent and immediate attention by the government. The World Health Organisation’s findings in 2020 indicated that about 30 percent of Nigerians have one form of mental illness or the other. With the COVID-19 pandemic, the security situation in the country and other social issues such as unemployment, it is believed that this figure may have gone up significantly. So, looking at that, you will say that possibly more than half of Nigerians are labouring under one form of mental illness or the other. Mental illness is not just about people misbehaving or those we see on the road; some have issues with the way they think or perceive things even though they are still able to function. But their level of functioning has been significantly reduced.

Predominantly, we will have anxiety disorders topping the chart, followed closely by depression. There are also suicide and suicidal behaviours. Substance abuse in the country is quite rampant. No gender is spared of mental illnesses, although some forms may be more predominant in a gender. The youths have a high prevalence of substance use disorders and anxiety disorders. Every age group is affected by mental illness right from the cradle, even the elderly.

What are the challenges of mental health in Nigeria?

The challenges of mental health are myriad. Topmost is the law governing mental health practice in our country.  If the law governing mental health and mental health practice is reviewed, even as done by the Association of Psychiatrists in Nigeria in conjunction with other stakeholders, we will have a better and more robust way of care for those who have mental illnesses. Presently, we have a mental health bill awaiting assent by the president after a very long due process of its review to ensure that it conforms to what is globally acceptable and after it has passed through the rigorous reviews of the National Assembly.

Secondly, the mental health policy which was revised in 2013 has not been implemented. In that policy, the focus is that mental health should be implemented and integrated into primary health care. Up till now, that is yet to be done. General hospitals, and especially the specialist hospitals, are meant to have psychiatrists in their employment. Currently, quite a number of them do not have psychiatrists in their employment.

Can you assess the adequacy of Nigeria’s mental health law in meeting the mental health needs of Nigerians?

There is a huge gap between the need and the availability of services. The burden of mental health in the country is quite huge. The available facilities and number of mental health practitioners are quite low. The number of psychiatrists in the country is possibly less than 300. We believe that possibly over 400 psychiatrists may have been trained in recent times, but many of these have had to leave the country for one reason or the other. The number of trained psychiatry nurses and clinical psychologists in the country is also quite low, and if you add all these together, you have a very disturbing figure. This is despite the percentage of mentally challenged individuals in the country that would possibly have doubled the 30 percent indicated by WHO.

Nigeria is said to have the highest caseload of depression in Africa. What could be responsible for this?

The world over, the prevalence of depression, Nigeria inclusive, is said to be between 5 and 10%.  Depression is one of the commonest mental illnesses that people face. With the prevailing socio-economic issues, insecurity, unemployment and the state of our health facilities, surely the figure is probably underestimated. These have implications for the mental health of people.

Should people with mental health issues be chained and locked up?

No, this is inhumane, and this is against the practice of mental health the world over. There is no reason whatsoever for people to be chained, to be locked up in asylums or all these places we see around. There are better ways of managing mental health issues; there are new medications too. Modern facilities where psychiatrists offer services have abandoned the use of chains and all other inhumane ways of managing cases.

What are the early predictive signs of mental illness? What are the socio-cultural beliefs about mental illness in Nigeria?

The early signs of mental illnesses include social withdrawal from people. Any deviation from the usual way an individual will think, talk, perceive situations around and relate to society may be symptoms of mental illness. For instance, because of depression, people tend to withdraw into their shells. When sleep, appetite and the way they relate with others are affected, a suspicion of depression can be magnified. Some people tend to have delusions, a false or a wrong belief, which is not in keeping with individuals’ social, economic, or even educational and religious backgrounds and is difficult to change such person’s mind.

People who have mental illness tend to see things others are not able to see; hear what others are not able to hear and feel what others are not feeling. They tend to lose touch with reality. And this depends on the severity of the illness. Some will be seen talking to themselves and running away, even from the people that they used to love and relate with. So, the symptoms are many and depend on the particular type of illness they may be experiencing.

The impact of our socio-cultural beliefs would manifest even in the people accepting that they are ill in the first place. It impacts their help-seeking behaviour and the outcome of mental illness. Quite a number of our people still believe that mental illnesses are spiritual and that people are afflicted with mental illness because of some past deeds or sins. They therefore will seek traditional treatments or spiritual intervention. Eventually, the presentation in the hospital is later than expected and the outcome of treatment is poorer. Even the treatment given in some places is inhuman because of some social-cultural beliefs about mental health and mental illnesses.

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How many doctors and how many facilities do we have in the country presently?

Due to the exodus of medical practitioners outside the country, I’m sure we cannot boast of 300 trained psychiatrists in the country to serve over 200 million Nigerians. The same thing can also be said of the clinical psychologists, the psychiatry nurses and other cadres of mental health workers in the country. The number is quite low.

Mental health care services are available largely in tertiary health institutions, including stand-alone facilities like the Federal Neuropsychiatric Hospitals in the country. Most of these are located in urban centres although more than half of Nigeria’s population live in the rural areas and would have to travel long distances to access care. We need to look at the available facilities and then see what can be done.

The law establishing primary healthcare integrated mental health into this level of care as the ninth pillar of primary care. However, as we talk now, the political will and the push to ensure that this is done is not there and therefore, the Primary Health Centers do not routinely offer mental health services. This step, if implemented, would improve the access of people with mental illnesses to care, remove stigma and discrimination as well as ensure early and prompt referral, if need be.

What should be the best model of mental health services in Nigeria to ensure universal mental health care for everyone irrespective of an individual’s socioeconomic level and residency?

The best model for mental health practice in this country will still be to have it fully implemented at the primary care level. By this, access to care will be fast and easy. People will not need to travel long distances to the urban centres to access care. In addition to having mental health fully implemented and integrated into primary health care, the general and the specialist hospitals should be mandated to have a mental health department in their institutions.

That way, even the process of referral can be easier because these are at the state level before they get to the tertiary centres that will oversee what is done both at the primary and secondary care level and see the more severe cases.

What should be the topmost agenda of the Federal Government to ensure universal mental health coverage for all?

The assent to the Mental Health Bill on the desk of the president and the subsequent full implementation of all that is written in that bill. Secondly, we need to make sure that the integration of mental health into primary healthcare is fully done and fully prosecuted. The allocation to mental health should now be a statutory budget line item, so that it is protected. The exodus of mental health practitioners outside the country needs to be stemmed to make sure that our well-trained hands are retained to cater for the people. It is our rough estimate that three out of every five newly trained psychiatrists find their way out of the country. Lastly, the National Health Insurance Scheme needs to cover more mental health conditions and include in their formulary the newer available medications in the country. This will be the panacea even for universal mental health coverage investment.