Oye Gureje, Professor of Psychiatry and Director, World Health Organisation Collaborating Centre for Research in Mental Health, Neurosciences and Substance Abuse, Department of Psychiatry, University of Ibadan, Nigeria, in this interview by SADE OGUNTOLA, speaks on the worsening mental health status of Nigerians and why it is particularly now striking in the elderly.
COMPARE the mental health of Nigerians when you started practicing as a physiatrist and now?
We haven’t been doing regular surveys to have information on the trend, so it’s difficult to be precise on this. One can just make generalisations about what the situation was then and what might have affected the situation now. We know that several things, including social and economic circumstances, affect individuals’ mental health conditions anywhere in the world, including Nigeria.
To that extent, situations like deepening inequality, banditry, civil turmoil and terrorism would have created a situation to make the mental health of Nigerians worsen. Again that is something one can surmise but we don’t have good epidemiologic studies on this. But in general, the profile of mental health conditions in Nigeria has likely taken a turn for the worse because of some of those conditions. For instance, the incidence of drug use or addictive behaviours has gone up. Also, mental health conditions like depression, anxiety, PTSD and others related to stress would have gone up, particularly in communities where social and civil upheavals have been more prominent.
Nature and nurture determine the course of many diseases; have there been genetic mutations to play up some mental health conditions in Nigeria?
The genetic makeup of Nigerians wouldn’t have changed in the last few decades. It takes a long time for major changes to occur. Even when people carry a genetic predisposition to a particular problem, they may never manifest the problem because the risk factors that will make the conditions emerge never turn up. So it’s not the genetic composition, it is certainly the social drivers that might have affected the profile and rate of mental health conditions in the country.
So, what exactly are these social drivers unique to Nigeria that may be pushing up cases of mental health conditions in people at risk, especially now?
Well, the economic well-being of people across the country has been going down for quite some time now. And we know that there’s a strong link between the level of poverty and a variety of mental and physical health conditions. Of course, other social problems that may be implicated include banditry, insecurity and unemployment. A lot of young people roam the streets for months before getting a job. Of course, all of those constitute risk factors for mental health conditions that we are witnessing in the country. For example, the ready availability of substances like tramadol to which people also get addicted is another factor. In the past, the only substance frequently talked about is cannabis.
Can we say therefore that socio-economic drivers and the fast eroding social support to cushion the effects of these social and economic drivers of mental health conditions account for increasing cases of mental health conditions now recorded in Nigeria?
Yes, both the risk factors and the reduction in the cushioning effect of social support may be linked to increasing cases of mental health conditions. Social support is one of the strongest buffers against a lot of mental and physical health conditions. The extended family structure is breaking down; urbanisation is affecting the social cohesion between people and the friendliness of their neighbours and our resilience against drivers of mental health is becoming less.
Some buffers are also breaking down as a result of social factors. Now many children are going away from their parents and living abroad. You find many households of elderly couples with no children or grandchildren around. Meanwhile, those are the things that create joy and create a buffer for them. This is in addition to the fact that they might not have access to financial security. Of course, we know access to pensions is limited. That is why we have one of the highest reported rates of depression among the elderly in Nigeria.
Can you quantify the high mental health conditions in Nigeria?
In the largest survey of ageing in Africa, conducted in Nigeria that we have done, we found that the rate of depression among the elderly is much higher than what is often reported in many parts of the world. It is much higher than we find in the younger population. It is not only in one study that the elderly in the country have been reported to be at increased risk for mental illnesses, especially depression.
In previously published studies, depression and many other mental conditions tend to be much more common among the young and tend to go down a little bit in old age. The elderly person is not supposed to be driven by the many day-to-day hassles; they are supposed to have a relatively stable life. But the reverse is the case here in Nigeria. The young people still have some hope that things will get better but for the older ones who have no other safety net, there is nothing to recourse to.
Also, non-communicable diseases like diabetes and hypertension, which tend to be more prevalent as people age, really cumulatively contribute to the increasing incidence of mental health conditions in the elderly especially when they go untreated because they have very little access to healthcare and there’s no health insurance to make health care accessible.
Going down memory lane, what were the prevalent mental health conditions you came across in the psychiatry clinic then?
In those years, still much more than now, people who eventually find their way to tertiary care, which is where I work, had very severe mental health conditions like psychotic disorders. And then a lot of neurological diseases, especially epilepsy were seen. This is no longer necessarily the case now depending on the hospital.
Anyway, the profile has changed. Now, we have more people coming to care because of drug addiction or addiction to substances that were completely unknown a few decades ago. Also, people are coming a little bit more now because of mental disorders like depression and PTSD due to an increase in awareness of these conditions.
What is your topmost contribution to the understanding and treatment of mental health conditions since you joined the profession?
My main interest is primarily in global mental health, which mainly consists of two major strands that I am doing. One is to assess the burden of mental health conditions in the society and then to find some answers on how to reduce the burden. I was involved in the largest Nigerian mental health survey which we did in different languages in Nigeria. Again, we did the largest study on the health and well-being of the elderly. Those are examples of some of the big studies quantifying the burden. We have also done many studies in which we were designing new interventions for some of the more common conditions in the country, especially depression, including depression occurring in childbearing women.
We don’t have enough psychiatrists in Nigeria, so we tried to test approaches that can be delivered by frontline primary care providers who are not physicians. They may be community health workers or community health extension workers to try and see how they can be trained to deliver those interventions and also to quantify the cost of doing so.
A large number of our people receive health care from traditional and faith healers. For many years, not just in Nigeria but in many parts of Africa, one of the aspirations of government is how to improve the services provided by those healers and especially how to reduce some of their inhumane or harmful practices. So we designed and implemented the first trial of a package of collaborative care for individuals with severe mental health conditions to be delivered by the healers and primary care providers. Those are some highlights of what we have done, especially in Nigeria.
The third major strand will be my involvement in policy. I have been the chair of the Mental Health Action Committee of the Federal Ministry of Health for many years and we were involved in drafting the current mental health policy in the country. Unfortunately, one of the frustrating things about working in this field in Nigeria is that you cannot get the government to move sufficiently fast enough to implement some of the things that you are doing. That policy even though adopted by the National Council of Health in 2013 has not been implemented.
Brain drain is a recurrent issue in Nigeria, we had one in the 80s and now we are into another phase. How has it impacted access to mental health care for Nigerians?
It is a major problem; it is particularly disheartening because it appeared that those at the helm of affairs have very little or a poor understanding of the impact of it. The doctors are trained to deliver service in our country, especially in a country where we do not have enough doctors to look after the people and health indices are so poor.
In the 80s, there was a big brain drain, especially of senior doctors, going out especially to the Middle East because income fell dramatically and many of them couldn’t pay their mortgages and all of that. What is happening in recent years is best likened to a flood. People, especially the young ones are leaving in a much larger number now.
In the last 2 years, more than 10 trained specialists, immediately after qualifying, have gone away from my department. Unfortunately, they are going to countries with about one psychiatrist to a population of about 100,000 unlike Nigeria, which has one psychiatrist to about a million people. This is due to a combination of pull and push factors. The push factors include poor emolument and poor conditions of service. The pull factors are the better conditions of service in the countries they go to and the aggressive recruitment efforts by those countries.
The World Psychiatry Association made me the chair of a committee several years ago to try and advise the world body about how to address the problem of brain drain, especially in sub-Saharan Africa. Some of the recommendations we came up with then include the fact that those countries should work more at retaining their trained workforce and the need for an international policy to discourage aggressive recruitment drive by high-income countries.
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