Mental Health: The danger of Nigeria’s single story

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Editor’s Note: This week’s Thought Leadership Article on Health was written by Dr Ukwuori-Gisela Kalu, a Consultant Clinical Psychologist and advocate for better mental health services in Nigeria. She writes about the sparse availability of mental health services, personnel and institutions in the country, discusses why this is so, and points out the slow but encouraging transformation taking place in both provision of, and demand for, better mental health care in Nigeria.

Mental illness is not uncommon in Nigeria. The World Health Organisation (WHO) estimates that four percent of Nigerians suffer from depression. Yet there is still considerable neglect of mental health in Nigeria, and those who visibly suffer from mental illness are largely stigmatized. For example, individuals who show symptoms of psychosis (hearing voices or seeing things that are not there) are often labelled as “crazy”, publicly beaten and deprived of rights essential to dignified living. Individuals suffering from mental illness are generally seen as dangerous, regardless of their type or diagnosis of mental illness.

As a Clinical Psychologist educated in the United Kingdom, I was excited to move home to Nigeria in May 2016 to use my skills and experience where opportunities for clinical work and research in mental health seemed infinite and invigorating. I currently work in private practice, both in Lagos and Abuja. I provide therapy for children, adolescents and adults, and I treat a variety of mental health difficulties and illnesses, such as depression, anxiety disorders, trauma and post-traumatic stress disorder (PTSD), addictions, and family and couples’ conflicts. I also provide training and corporate services.

Mental illness in Nigeria still carries with it a lot of stigma. Image courtesy: sqonline.ucsd.edu

Due to the relatively large number of psychiatrists involved in the treatment of mental illness in Nigeria, I often get mistaken for a psychiatrist or ‘shrink’. Psychiatrists are medical doctors who have special training in diagnosis and treating mental illness, mostly with medication. I am also a doctor specialised in mental health, but I do not prescribe medication. Instead I provide evidence-based ‘talking therapies’, such as Cognitive Behavioural Therapy (CBT), Behavioural Couples Therapy (BCT), Mindfulness Based Cognitive Therapy (MBCT), or specialist trauma therapies.

Since I started my practice here in Nigeria, I have seen a number of individuals, both adolescents and adults, with a variety of difficulties. Sadly, the stigma around mental health in the country has often meant that the individuals I see are more severely ill before they access help through services. The relative lack of coordination between mental and general health services has caused further difficulty at times. For example, individual’s mental health histories do not routinely get recorded and a confidential electronic patient record system in general does not exist in Nigeria.  In comparison to the UK, there are no Accident and Emergency (A&E) services that individuals at acute risk of suicide can freely walk into.

Part of the problem has to do with the country’s lackadaisical approach to mental health policy implementation. The country’s only existing Mental Health Policy document was formulated in 1991. Although a bill for the establishment of a Mental Health Act was introduced in 2003 and re-introduced to the National Assembly in 2013, this is yet to be passed into law. No desk exists in the ministries at any level for mental health and only 3.3% of the federal government’s health budget goes to mental health.

In addition to this lack of political will where mental health is concerned, numbers of trained and specialised mental health care professionals in the country are also low. According to the WHO-AIMS Report, as of 2006, the total number of mental health professionals working in mental health facilities or private practice in the country was 3,105, which means there were just over 11 mental health professionals per 100,000 people. Of this number, there were only 42 psychiatrists (0.15 per 100,000) and 20 psychologists (0.07 per 100,000). This lack of specialised personnel also means that, according to the WHO-AIMS report, physicians in PHCs are allowed to prescribe psychotropic medications without restrictions. There is also a relative lack of training and research in the area of mental health, and there is no coordinating body to oversee public education and awareness campaigns on mental health.

In the absence of a Mental Health Act passed by law and with a lack of adequate mental health infrastructure, low numbers of professional personnel, training and research, Nigerians suffering from mental illness are at risk of being subjected to prejudices, discrimination, stigmatization and abuse.

This lack of policy and regulation for mental health has also created an avenue for a variety of different professions currently concerned with the treatment of mental illness in Nigeria, including traditional and spiritual healers, counsellors, life-coaches, psychiatrists and psychologists, to flourish. Although an increase in services to treat mental illness is generally welcome, there is a danger of malpractice that comes with the lack of standardised and evidence-based diagnoses and treatment.

People suffering from any form of mental illness are encouraged to reach out for help. Image courtesy: Nigeria Suicide Prevention Initiative

Nevertheless, my impression is that Nigerians are slowly becoming more willing to talk about mental health, and innovative approaches to mental health services are beginning to spring up. I welcome the recent establishment of the Nigerian Suicide Hotlines by the Nigeria Suicide Prevention Initiative.

I have also recently become a Patron for the mental health charity Mentally Aware Nigeria Initiative (MANI). MANI is a great advocate of mental health literacy and awareness in Nigeria. They provide information and resources about mental (ill) health, and they are currently running a number of online awareness campaigns, for instance #NotACharacterFlaw and events. For more information visit  @MentallyAwareNG.

To ensure a mentally aware and healthy Nigeria in the future, there is an obvious need to establish robust mental health law, policy and regulation. These should include not only measures for treatment, but also for the prevention of mental illness. There should also be evidence-based recognition and definition of the wide range of mental illnesses to enable the adoption of case specific treatment protocols rather than lumping all cases of mental illness together.

Finally, legislation should set appropriate standards for practice in the area of mental health at all levels of service delivery, including ‘western’ psychiatric/psychological practice, faith or religious based practice, and traditional or complementary alternative practice.

While these systemic changes to the way we relate to mental health in Nigeria might take several years to accomplish, my immediate hope is for continued conversations and discussion about mental health and mental illness. Let’s talk more about mental health as individuals, as family-systems and communities, and as a country all together. We must remember that “There is no health without mental health”.

Discussion3 Comments

  1. This is a well written article, and I enjoyed reading it. It clearly outlines the issues in the country and reflects the numerous challenges that exists within our health system, with mental health been no exception. I applaud the efforts of the players who are working to address this, especially the author.

  2. Very timely piece of information, coincides with recent trends in the country. However, two points hit me as bizarre; having cited inadequate records,how palatable is the notion that there are only 42 psychiatric doctors in mental health institutions in Nigeria? Secondly, psychiatry is a prominent part of the general training of physicians in The country; as such primary care physicians managing psychiatric cases is not a misnomer especially given the realities in the health system as you pointed out.

  3. Ogonda Ada Bennett

    I agree with “Adaeze”. Well thought out and written, thanks to the author. I am very happy that there are people like the author who are doing their best to positively contribute to this much-neglected area. Do keep up the good work.

    I just wanted to add something though. Unfortunately in the Nigerian society, especially in the more Christian south, the kinds of issues the author is describing are sometimes ascribed to “evil spirits” with the victims/sufferers put through (often physically and mentally dangerous) “deliverances”. Don’t get me wrong, I am a Christian myself but I just feel that some of those people who are prayed over, and beaten and starved, etc, in our churches in the name of deliverance could well benefit from some of the therapies and/or psychiatric treatment the author has described. I wish we could move to the stage where people suffering from psychological and/or psychiatric disorders are treated with the care and compassion they deserve.

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