The mental health problem is global and millions of people are affected. It exists in Nigeria such that it has become a public health issue, yet the mental health system in Nigeria appears to be inept in meeting the needs of sufferers of mental illnesses. This paper discusses the increasing importance of mental illness as a public health concern globally with particular emphasis on the Nigerian mental health issue. It is organised into various sections discussing the global mental health problem; the Nigerian mental health problem and system.
It concludes with global guidelines in mental health and personal recommendations. Introduction Mental health is defined as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. ” (WHO 2011). Despite the dearth of required attention due it, mental health forms a vital aspect of overall health. The global prevalence of mental illness is enormous with 450 million people affected(1).
14% of worldwide disease burden is attributed to mental illness as an entity(2). A relationship is known to exist between mental and physical illness as individuals with mental illnesses are known to be more predisposed to physical illnesses(4). The most affected persons have been found to be located in developing nations (75%) and have only marginal accessibility to the necessary care and services(4). World health Mental Survey Consortium 2004 (WMHS2004), states that the health service gap for mental disorders was 35. 5-50. 3% of severe conditions in developed nations and 76.
3%-85. 4% in developing nations(1). Glaringly evident is the extent of the unmet need for mental health service in developing nations, Nigeria not being an exception. Earliest recognition for mental health internationally came about in the 1990’s with the World Development Report (1993) by the World Bank. (5). It exhibited the global burden of disease caused by mental disorders and revealed that the burden from mental illness was substantial in low-and-middle resource nations, regardless of prevalence of infectious diseases and non-communicable diseases.
The 2001 World Health Report; New Understanding, New Hope (WHO 2001b) was also a document of significance in the field of Mental Health; equally highlighting fresh evidence as regards the burden of neuropsychiatric disorders and the dearth of efficient response mechanisms in developing nations. It was accompanied by recommendations for future interventions(6). As a consequence of the two-fold health burden in developing nations, policies focussed on mental health programmes are still under-prioritized(5).
There is, however, growing acknowledgement of the relevance of mental health as regards the overall wellbeing and health of the populace(5). Regardless of the growing awareness, it is apparent that the necessary wherewithal to advance mental health in developing nations is still severely lacking. National and local strategies for promotion of mental illness are practically non-existent or inefficiently executed(5). This apparent predicament as regards mental health issues has led to developing of innovative mental health programmes for low resource nations4.
The WHO Mental Health Gap Action Programme (mhGAP) positions itself as one of such strategies towards improving service delivery for mental, neurological and substance use disorders (MNS Disorders) in all nations, with its primary focus on low-and-middle resource nations(4). The programme presents stakeholders with comprehensible and logical guidelines towards improving service delivery and also purposes to strengthen stakeholder obligations for effective resource provision for MNS Disorders(7). THE NIGERIAN CONTEXT
Even though mental health is a notable public health problem it suffers extensive governmental disregard. Effective solutions to the issue are yet to be proffered by the government despite the increasing volumes of affected persons that take to wandering the streets and portend a public menace(8). A recent community-based intervention in Nigeria depicted that only 9% of identified mentally-ill persons receive treatment(9). Essentially, many are left to expire on roadsides with no intervention. State of affairs of mental health system in Nigeria can indeed be termed as non-progressive and grossly insufficient(3).
This is substantiated by the fact that the National Mental Health Policy formulated since 1991 has yet to be reviewed and remains the only policy document for mental health in Nigeria(10). The policy embodies 14 commendable statements, addressing the rights of mentally-ill persons and was further reinforced by a National Mental Health Programme and Action plan which is sadly yet to be implemented(10). Currently, Nigeria’s Mental Health Legislation is outdated, as the nation still uses the Lunacy Act Cap. 112 of 1916. The laws are clearly not in accordance with modern-day opinions of mental illness as treatable disorders(10).
MENTAL HEALTHCARE In Nigeria, an estimated 5. 8% of Gross domestic product (GDP) is targeted at overall health, of which less than 1% of total amount spent on health is allotted to mental health programmes(6)(10). As with most services in Nigeria, mental healthcare delivery is skewed in favour of urban and regional settings with respect to availability and accessibility(12). Consequently, there is a shortage of mental health institutions in the country and those available are predominantly federal-government owned with private-sector mental health facilities being virtually absent(10)(11).
The bulk of mental disorders managed by clinicians in Nigeria are positioned in primary healthcare which in itself is underdeveloped(12). Treatment cost is essentially out of pocket with only a portion of the population (civil servants) benefiting from short-lived mental health coverage via the National Health Insurance Scheme (NHIS)(11). Disability benefits are not available for the mentally-ill as is reflected in developed nations like United Kingdom.
Even though intersectoral collaboration is encouraged towards promotion of mental health initiatives; Nigeria has no available system of government to harmonise supervision of public education and awareness programmes in Mental Health(11). An organisational structure of mental health services is non-existent for this unique specialty(11). Current human resource allocation depicts approximately 0. 1 psychiatrists/100,000 population; 4 psychiatrist nurses and 4 psychiatric beds /100,000population(3), giving an estimate of 130 psychiatrists resident and practising in Nigeria most of which are in the country’s large institutions(12).
A large of proportion of specialists has been lost to the prospect of greener pastures in more developed nations. Mental Hospital Units offer a bulk of admissions with Inpatient units following closely(11). 45% of the attendees to mental health facilities are women; 2% are found to be adolescents and children. (11) Research which is a valuable tool for advancement in Mental Health is minimal in Nigeria. Ongoing research in Nigeria ranges from descriptive studies to large multicenter epidemiological studies; this is in the face of scarce resources(12).
Likewise, due to these resource limitations, very few intervention studies have been recorded(12). Dearth of such studies, limits the potential for progress and international recognition. LOCAL RESPONSES As regards, mental health in Nigeria, causative factors for mental illness range from spiritual origins in Central Nigeria to substance abuse in Northern Nigeria(10,11). Hence, several studies have arrived at the conclusion that opinions concerning the varied causative factors of mental illness bear a strong correlation with stigmatization and care-seeking behaviours(13).
Previous studies in Sub-Saharan Africa, propose a predilection for unorthodox approaches to mental health management(14); with an estimated 70% of mental healthcare delivery in Nigeria being through religious establishments and traditional healers(12). As a result of this realisation, Professor Adeoye Lambo (Nigerian Psychiatric pioneer), established the ‘Aro Village System’. This was an innovative strategy to address the dearth of specialists in mental health services whilst incorporating the activities of traditional healers into the mechanics of orthodox treatment modalities(13 14).
Till date the ‘Aro’ innovation stands out as one of the most progressive contextual approaches to management of mental disorders in Nigeria and has been exemplified in various low-resource settings(13 14). Token responses to the Nigerian mental health issue include, the previously mentioned Mental Health Policy which advocates for “integration of mental health promotion, treatment and rehabilitation into primary healthcare services”(14) , all which are in line with the Alma-Ata Declaration (1978).
Though laudable and in keeping with current global public health principles the successful integration of these services presents itself as an ongoing challenge in Nigeria. Primary Healthcare Clinics (PHCs) are in reality, existing and operational in each Local Government Area (LGA) in Nigeria serving about 50,000 persons/LGA. They are staffed by nurses and community healthworkers with minimal mental health training, similarly general practioners found in these facilities are themselves not ideal in their diagnosis and management of mental disorders(17).
Evidently, in view of the existing circumstances in Nigeria of shortage of specialized personnel in mental health, primary healthcare workers form a useful resource to draw upon in provision of much required services. It is however uncertain that the proficiency level of these staff will adequately cater to the care of affected persons. It is of essence to note that PHCs in Nigeria are yet poorly resourced and organised, hence incorporation of an affordable and efficient mental healthcare system into existing primary healthcare will require proper synchronisation at all levels of government(17).
In view of poor federal government support of mental health strategies, state governments have taken to development of local strategies to handle the mental health issue. Examples of such include the Lagos State Mental Health Programme which acts to deliver the main objectives of the yet adopted mental health policy(18). The Lagos State Mental Health Team is equally a local initiative consisting of individuals and organisational bodies. It is a grassroots advocacy and public-education organisation, promoting prevention and care of affected persons.
Other Non-governmental Organisations partake in this mission; though few, their activities have registered minimal impact in the growing challenge. Without adequate and sustained government and international support, the crisis in mental health may sadly be ongoing. CONTEMPORAY THINKING/GLOBAL GUIDANCE In accordance with the fundamental principles of health promotion (Ottawa Charter 1986); mental health promotion has earned considerable recognition as a practicable tool in bridging the gap in mental health services globally.
Undoubtedly, the Ottawa Charter forms the basis for improvement in all aspects of health, mental health included. Mental health promotion focuses on delivery of effective and innovative health programmes whilst looking into the wide-ranging determinants of mental health with the aim to reducing existing health inequalities(19). Several systematic reviews validate the notion of mental health promotion and clearly demonstrate the sustainable effects of implementation of strategies which include, enhanced mental wellbeing, reduction in risks of mental illness and observable advantages to the economy and society in general(19).
Current global practice also, embraces community mental health programmes, and purposes to deinstitutionalize mental healthcare treatment. This shift arose due to the emergent realization that management of mental disorders was much more than just pharmaceutically based; rather a re-orientation of services was required, with more attention placed on rehabilitation and societal integration of affected persons. Consequently, community care, which was previously regarded as out-patient care has now expanded to include professional care in community settings with support services(5).
In line with the Lancet series on mental Health, the current focus is on action; one of such highlighted means of action is via the Movement for Global Mental Health innovation which originated on World Mental Health Day 2008. This intervention aspires to strengthen efforts towards transforming services by advocacy and improving availability of online literature resources, thereby bringing about the required reform in mental health services in Nigeria(6).
WHO’s current petition of member nations to improve supportive activities towards mental health services comes in line with the Lancet series of papers on global mental health(4). The commissioning of The Lancet series of papers (2007), aimed to review the existing conditions of mental health in developing nations in order to evaluate the evidence related to proper management and to reveal the prevailing obstacles to change(6); several of which are in existence in Nigeria. CONCLUSION The various global guidelines regarding mental health, though creditable, are sadly yet to be effectively implemented in Nigeria.
Equally is the case with the Lancet series ‘Call to action’. The significance of contextualising these approaches to mental healthcare services cannot be over-emphasised; as the recognition of mental disease in a setting depends largely on meticulous appraisal of the prevailing culture, norms and beliefs. Understanding of public outlook to mental disorders and its management is a fundamental requirement to successful implementation of community-based programmes in Nigeria(14) as well as mental health promotion interventions.
Nigeria as a nation with its attendant challenges with poverty, unemployment, and communicable diseases requires a custom-made strategy for mental health preferably developed domestically. Nigeria like several low-and-middle income nations are yet to make the shift to community-based services in mental Health, which can be attributed to limited political will and inefficient advocacy(6). As long as mental health issues are neglected and marginalised in Nigeria, then the nation is deficient. As so fittingly stated by WHO, there is “No health without Mental Health”.
Efforts need to be reinforced towards effective integration of mental health services into PHCs, as workers’ at this level may form a foundation for provision of mental healthcare services to the populace with adequate training and service organisation(17). The benefits of task-shifting also need to be considered critically. Finally, effective actions are required towards increasing research potential, as outcome of these researches will ultimately guide stakeholders in adequate resource allocation to mental health strategies.
The Mental Health situation in Nigeria is indeed in a state of emergency. REFERENCES 1. Detels Roger; Beaglehole Robert; Lansang Mary Ann; Gulliford Martin. Oxford Textbook of Public Health. Fifth Edition; Pages 1081-110; Oxford University press; 2009. 2. Movement for global mental health – lancet series on global mental health http://www. globalmentalhealth. org/articles. php? id=16;menu_id=0 3. Gureje O, Chisholm D, Kola L, Lasebikan V, Saxena S. Cost-effectiveness of an essential mental health intervention package in Nigeria.
World Psychiatry 2007; 6(1):42–8. http://www. who. int/entity/choice/publications/p_2007_cea_mental_health_Nigeria. pdf 4. WHO Mental Health Gap Action Programme (mhGAP) http://www. who. int/mental_health/mhgap/en/index. html 5. Merson. M, Black. R, Mills. A. International Public Health; Diseases, Programs, Systems and Policies. 2nd Edition; London: Jones and Bartlett; 2006. 6. Eaton J. A new movement for global mental health and its possible impact in Nigeria. Nigerian Journal of Psychiatry 2009; 7(1). http://www. globalmentalhealth.
org/downloads/Advocacy – NJPsych_MGMH_Published %2822 KB%29. pdf 7. Patel V, Garrison P, Mari J de J. The Lancet’s series on global mental health: 1 year on. Lancet 2008;372(9646):1354–7. http://www. ncbi. nlm. nih. gov/pmc/articles/PMC2570037/ 8. Nnamuchi. O. The Right to Health in Nigeria ;Aberdeen: 2007. http://ssrn. com/abstract=1622874 9. Gureje O, Lasebikan VO, Kola L, Makanjuola VA. Lifetime and 12-month prevalence of mental disorders in the Nigerian Survey of Mental Health and Well-Being. The British Journal of Psychiatry 2006; 188(5):465–71.