•Psychiatric patients, doctors, hospitals stigmatized
By Nnamdi Ojiego
Last November, a popular Nigerian movie star, Mrs. Chacha Eke-Fanni, recounted how she struggled with bipolar disorder and its impact on her marriage.
According to her, she suddenly “went mad” and destroyed every one of her family’s belongings including her children’s toys.
She acknowledged at that time, the family was ignorant of mental illness and blamed everything and every one possible as they felt it was either a demonic attack or voodoo.
“We attributed it to demonic attacks, voodoo, or marine spirit”, she had narrated.
Eke-Fanni was not the only celebrity who has suffered mental illness in recent times. Last year, another famous actress in the country, a woman, was reported to be struggling with a mental health condition.
Their experiences underscore the seriousness and level of prevalence of mental health problems in Nigeria.
According to a recent World Health Organization, WHO, statistics, about 50 million Nigerians or 25% of the country’s population are currently suffering from various degrees of mental illness or disorder and without access to psychiatric health care. This, according to the data, means that one in four Nigerians has one form of mental illness or the other.
The notion most people have about mental illness in Nigeria is that of people walking the streets naked or in tattered clothes, said Hannah Esuuknte, an Occupational Therapist at the University of Port Harcourt Teaching Hospital, in Rivers State. Esuuknte, who is also a therapist at ELPIDA Shelter Rehabilitation Center, Port Harcourt, added that not many people were aware that depression, anger issues, eating disorders etc are mental ill health and as such, many don’t take their mental health as a priority.
Nigeria is one country where people do not examine their mental state. Experts attribute this to cultural issues, poverty, inaccessibility to treatment centres, ‘spiritualization’ of mental health disorders, lack of insight/limited awareness, stigma and shame attached to mental illness in the country.
Studies by Africa Polling Institute in collaboration with EpiAFRIC found that many Nigerians still associate mental illness with evil spirits, voodoo and related supernatural causes.
This is why children with mental health disorders are labelled witches and accused of being possessed by evil spirits. Many children are going through adverse childhood experiences at home and these predispose them to mental health issues both in childhood and adulthood. These adverse childhood experiences include physical, emotional and sexual abuse.
Sadly, not many people know that children can suffer from depression, anxiety, etc, hence the reason they are labelled witches. Studies have shown that most mental health issues start to manifest at the age of 14.
A mother who simply identified herself as Felicia disclosed that her first child showed signs of mental disorder very early in life. “It was in 2016 that we started noticing the unusual behaviour”, Felicia noted. “We thought she was possessed by an evil spirit and took her to many churches and prayer houses for deliverance but instead of getting better, my daughter’s condition was deteriorating. Luckily for us, a friend encouraged us to seek professional help and we heeded. To the glory of God, my child is doing okay today.”
It was in light of this that Lucy Abeng, a mental health advocate, founded the Mental Health for Youth Initiative, MHYI, to educate and counsel young people on mental health issues. “I started this initiative after realising the nature and prevalence of mental health issues among young people between the ages of 14-25”, Abeng said.
“We explore several forms of art to promote mental health conversations. We have implemented several projects for specific demographics within our target group. Our ‘Every Mind Matters’ project is for groups in orphanage homes and IDP camps; while the ‘Mental Health Awareness and Intervention’ project is for secondary school students.
“We advocated for the passing of the Mental Health Act which became a law in January of 2023 and currently advocating for the decriminalization of suicide by the Nigerian government. We hope to extend the impact of our work to every part of the country and create a system that every young person can benefit from as we believe mental health accessibility is a universal human right”, Abeng explained.
Poor public education about mental health has allowed many misconceptions and low public acceptance of mental health patients to thrive. A majority of the population often seeks treatment from traditional and supernatural healers, given the predominant view of supernatural causation. According to a research report by Oyedeji Ayonride, approximately 70% of mental health treatment is provided through non-orthodox means. This, stakeholders opined was due to the inaccessibility of mental health care centres and professionals, as well as the high cost of services.
Furthermore, Human Rights Watch reported in 2019 that thousands of people with mental illness are living in ankle chains at institutions designed for care. These often religiously-run centres, the report added, were the only accessible option for many families.
Pastor Jude Egbuso of Salem City Sabbath Mission, Orlu in Imo State, who doubles as a traditional healer of mental illness because he inherited the practice from his father and great grandfathers, confirmed that patients are chained when necessary.
“I don’t use an iron hand on my patients because it’s not good. Again, flogging and hitting them might worsen their problem. However, when the patient is violent especially, due to substance abuse, we will have no option than to put them in shackles until they regain their sanity.
Jude who handles all kinds of mental illness including one supposedly caused by a spiritual attack, said he uses different treatment options depending on the type of the mental illness.
“The first thing I do is to find the cause of the disorder and administer treatment accordingly. If the mental disorder is caused by substance abuse, I will put the person in chains because they are always violent. I don’t rely on prayers alone. I heal with coconut water, roots, herbs, etc. After praying for my patients, I give them drugs. What prayers do is to help the drug to work. We also apply talk therapy by showing empathy and making victims feel accepted.”
Experts say signs of mental illness are many and presentation would depend on type. According to them, most people usually see increased aggression, unwarranted irritability, poor concentration, suicidal thoughts, memory issues and poor sleep as main signs.
Some of Nigeria’s most prevalent mental illnesses include depression and anxiety disorders. For example, in a 2017 Global Health Estimates by WHO, about 7 million Nigerians (3.9% of the population) had depressive disorders, and 4.9 million Nigerians (2.7%) had anxiety disorders. On top of this, substance abuse, bipolar, schizophrenia, and personality disorders are common in Nigeria. With the prevailing socio-economic issues, insecurity, unemployment and the state of the country’s health facilities, the figure would probably be higher today.
Dr. Dapo Adegbaju, Consultant Psychiatrist at the Federal Neuro-Psychiatric Hospital, Yaba, Lagos, affirmed that there is a connection between substance abuse and mental health.
“Substance abuse”, Adegbaju explained, “could worsen existing mental health conditions or lead to new ones. It can also lead to disruption in the normal brain chemistry leading to an abnormality in thinking, feeling and behaviour.”
Similarly, a psychiatrist at the Alvan Ikeoku University of Education, Owerri, Imo State, Dr. Julia Ogwunga, added that some people may become excessively suspicious about their relatives or things happening around them.
“Such a person”, she noted, “may believe that their mother, father or child is the enemy while some may be hearing strange voices of people they are not seeing or see things other people do not see. There are somatic symptoms such as the feeling of pins and needles or crawling sensations on the body or head.”
Tackling the scourge
Experts say mental illness cannot be completely eradicated anywhere in the world but could be managed. According to them, tackling the mental health scourge in Nigeria would require a concerted effort from the people, government, religious leaders and the media.
A mental health advocate, Ifeoluwa Esther Ogunkola, who uses her platform to offer support, resources, and encouragement to individuals struggling with mental health issues, said ending the scourge requires a multi-faceted approach including raising awareness, reducing stigma, providing support, improving access to care, and collaboration among local and international bodies.
“Our organization partners with various stakeholders, including government bodies, community leaders, and healthcare providers, to promote mental health awareness and support”, Ogunkola said.
Serious challenges to resolving mental cases in Nigeria include the dearth of professional psychiatrists. To worsen an already bad situation, healthcare professionals are leaving the country in droves for greener pastures abroad. Stakeholders are worried about the collapsing healthcare system and the lack of human and material resources to handle rising cases of mental illnesses.
A report from the International Centre for Investigative Reporting (ICIR) in October 2022, revealed that the number of psychiatrists in Nigeria has reduced to 200. According to the report, there is now, one psychiatrist to approximately 1.9 million Nigerians whereas the standard practice is for one psychiatric doctor to take care of 10,000 patients.
The President of the Association of Psychiatrists in Nigeria, APN, Prof. Taiwo Obindo, who confirmed the development added that up to two-thirds of well-trained and certified psychiatric doctors leave the country annually, creating a negative situation in Nigeria.
The situation, he noted, has made accessibility and deliverability of psychiatric care relatively difficult.
The same is the fate of the clinical psychologists, psychiatry nurses and other cadres of mental health workers in the country. Psychologists are key professionals in providing services for people with mental conditions such as behavioural problems, learning difficulties, depression, and anxiety. Currently, there are only 319 licensed clinical psychologists that are registered with the Nigerian Association of Clinical Psychologists, NACP.
Another significant issue is Nigeria’s lack of access to mental health services. Unfortunately, the limited services are largely in tertiary health institutions. Most of these are located in urban centres even when more than half of Nigeria’s population live in rural areas and would have to travel long distances to access care.
Mr. Pius Umeokafor who lives in a remote village in the Aguata area of Anambra State, said they are left with no options than to patronize churches and traditional homes. “Even the traditional healers are far from us. When we have cases of mental disorder in our community, we take the victim to churches which are easily accessible. However, if it’s not what the church can handle, we would then take them to a native doctor. That’s our predicament, we don’t have any mental hospital around this area.”
Funding is a big drawback that prevents seeking help and complying with treatment. The federal government has continuously earmarked less than 15% benchmark of health sector budget allocation agreed upon in April 2001 by leaders of the African Union, AU, at Abuja. Despite the low budget allocation for health care in Nigeria, mental health care does not have a clearly defined allocation from the total health care budget allocation. However, Business Day and Business and Financial 2023 revealed that the government’s total expenditure on mental health is about four per cent of total government health expenditure.
Help for mental health patients can come in the form of therapy, medication, support groups, and lifestyle changes like exercise and self-care.
“Treatment of mental illness comprises of what we call the biopsychosocial model”, said Ogwunga. “Biological model is when medications including surgery are used by the psychiatrist. In the psychological model, the clinical psychologist makes use of talk therapy, which is of different types. However, the social model is where family members, friends and social workers give their support to the person suffering a mental disorder.
Ogwunga noted that culture also poses barriers to treatment. She said: “Our culture believes that all types of mental illness are due to evil spirits. Because of this mindset, some believe that those with mental illness don’t need treatment since their suffering is well deserved. However, many others believe that orthodox medicine cannot take care of spiritual things.
“Culturally, depression is not seen as an illness. Therefore, people who suffer from depression are seen as being weak. They are expected to brace up and shake off their depression. So when they finally decide to help their people with mental illness, they turn to the native doctors and for the modern ones, they turn to their churches, pastors, priests, and imams. And by the time they finally decide to seek orthodox treatment, the illness has deteriorated, making treatment difficult. Thus because of these myths, people living with mental illness are stigmatized.”
“I want to use this medium to appeal to the people that they should stop sending their loved ones who have mental health issues to native doctors and churches or prayer houses. When they do this, they are prolonging the brain destruction caused by these mental health issues. And they face dehumanizing conditions in such places, such as flogging, chaining, denial of food, sleep deprivation, etc. All contribute to the worsening of their mental health conditions.”
Also, Adegbaju pointed out the need to integrate mental health with physical health centres. This, he noted, would go a long way to demystifying the myth that people with mental illnesses are dangerous; reduce stigma and help in recovery.
“Making mental health treatment accessible will involve bringing treatment centres close to where people live, like at the primary health centres, PHCs. For this to be effective, the workers at PHCs need to be trained and retrained to be able to diagnose and treat minor cases and then refer serious ones to specialists. There could also be a timetable for psychiatrists to visit these centres to consult with patients.
“Again, treatment for most patients is out of pocket. Therefore, making insurance accessible to all will go a long way to help fight the scourge of mental illness. It is also important that the government encourage doctors to specialize in psychiatry. Nurses and other mental health workers can also be given incentives to get more people into the field of mental health”, Adegbaju stated.
Managing Mental Illness
Psychiatrists say having mental health issues is not the end of the world as patients could lead a normal life as long as adequate care is given. “However, it is better to start the treatment as early as possible for a better result”, suggested Dr. Ogwunga stated. “Because the later it takes to get treatment, the more difficult it will be to get a good outcome. It is important to know that mental illness damages brain cells. So the longer it takes to get treatment, the more the brain cell damages.
”In the treatment of most mental illnesses, what we aim at is getting the people concerned back into the society to function. Using medications, most of these mental illnesses are managed, not cured. It is just the same as managing hypertension or diabetes.”
For Dr. Obindo, management is the key. “We often talk about the management of patients. There are a group of mental health conditions that are chronic and some that would need lifetime management. Since mental illness can recur, one can only talk about the elimination/ eradication of symptoms or say the person is symptom-free. Management could mean that the person can be functional or has reverted to his pre-morbid level of functioning”, he explained.
Mental health patients often experience severe human rights violations and discrimination. This is because mental illness is still described with derogatory, discriminatory and stigmatized conditions. Regrettably, even the doctors, nurses, and other mental health professionals are not immune from stigmatization by the society. And the hospitals where these treatments are given are also stigmatized by the people.
A good example is the phrase, Yaba Left, which derogatorily refers to the popular Federal Neuro-Psychiatric Hospital in Yaba. It is also an insulting way of telling someone that they need a psychiatric evaluation. This points to the reason why not many people want to specialize in Psychiatry. Stakeholders say it would take consistent health education and advocacy to change this perception as this is the picture inculcated into people as children and further solidified by what is presented on television in drama and plays.
Sharing his experience, Adegbaju said most people erroneously assume that for you to be taking care of psychiatric patients, they must have a little bit too.
In her part, Dr. Ogwunga stated that one of the challenges most psychiatrists face in treating patients is stigma. “Just as our patients are stigmatized, so are we. Even before I went to specialize in psychiatry, my family members and friends were telling me soon, I would soon start behaving like them. And when I go to some places and introduce myself as a psychiatrist, many people squeeze their faces, while some will let out a big laugh. So the stigma towards the mentally ill and those who care for them is still high.”
Reacting in the same vein, Dr. Obindo added that psychiatrists are called names because of their career choices. “Yes, they call us names”, he asserted. “Not many who are your friends would venture to visit your house for fear of being labelled a patient. Sadly, they believe that all psychiatrists or mental health practitioners behave like their patients.”
But it is not all gloomy. There is a ray of hope following the signing into law of the Mental Health Bill by President Muhammadu Buhari earlier in the year. The Bill, harmonised by both Houses of the National Assembly in 2021, is the first Mental Health Act post Independence and has replaced the Lunacy Act of 1958.
Stakeholders had expressed optimism that the law would go a long way in empowering those suffering from mental illness, with certain rights. Obindo described it as a great relief and a victory for mental healthcare and practice in Nigeria. “A final culmination to over two decades of several efforts by the Association of Psychiatrists of Nigeria now has an Act/Law on Mental Health governance and we are now part of the global space with best global practice,” he stated.
Some provisions of the law created a Department of Mental Health Services in the Federal Ministry of Health and a Mental Health Fund. The new Act covers people living with epilepsy, learning disabilities, etc so that they don’t continue to suffer dehumanized practices being used on them, and will help to establish human rights protections for those with mental health conditions, such as banning discrimination in housing, employment, medical, and other social services.
It will also address the way and manner mentally ill populations are to be catered for without stigma or discrimination and also form global best practices in enshrining the human rights of the mentally ill, how care can be accessed, and outlawing chaining or other forms of coercion.
The law will regulate the activities of mental health practitioners, eliminate stigma and discrimination, and help in addressing the issue of funding for mental health care in Nigeria.
The transition from the “Lunacy” law to the Mental Health Act is a laudable achievement. However, it is crucial for all stakeholders to work together to create a supportive environment for people with mental illnesses and ensure that they receive proper care and treatment. This will require a comprehensive approach that involves collaboration between federal, state and local governments, healthcare providers, civil society organisations, and the general public. With collective efforts, Nigeria can make significant progress in addressing the needs of people with mental health conditions and promoting their rights and well-being.