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Mental Health: The danger of Nigeria’s single story

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.

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.

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”.

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Wealth from mental health

Promoting good mental health in the workplace is one of the most important things an employer can do to improve their organisation and boost their business. The way employees feel, think and act impacts on their productivity, their communication and on their ability to maintain safety at the workplace. With mental illnesses (such as major depressive disorders and anxiety disorders) being a leading cause of non-permanent disability worldwide, the promotion of good mental health in the workplace is now recognized as a global priority.

A large proportion of our adult lives is spent at work, and the experiences we make in the workplace significantly contribute to our overall health and wellbeing. Research shows that work is generally good for health. As well as financial reward, work provides many of us with a sense of identity, social contact and support, increased self-esteem and social status. However, a negative work environment can lead to physical and mental ill health, harmful use of substances and/or alcohol, and lost productivity.

Globally, more than 300 million people suffer from depression, and more than 260 million people are living with an anxiety disorders. In Nigeria, estimates by the WHO-AIMS Report (2006) suggest that 7,079,815 million Nigerians suffer from depression (that is 4% of the population) and 4,894,557 million Nigerians suffer from an anxiety disorders (that is 2.7% of the population). Depression, anxiety disorders, and other mental illnesses can cost employers a lot of money. In fact, a recent WHO led study estimated that depression and anxiety disorders alone cost the global economy US$ 1 trillion each year in lost productivity. Specific estimates for Nigeria are yet unknown.

On the other hand, organizations and employers who put in place workplace initiatives that promote good mental health, and support employees who have mental health difficulties, see gains in their productivity at work, and available cost-benefit research on strategies to address mental health points towards net benefits. A recent study estimated that for every USD $1 put into scaled up treatment for common mental illnesses, there is a return of USD $4 in improved health and productivity.

Of course, the reasons for promoting good mental health go beyond an organization’s expenditure. Supporting employees in feeling their best also reduces suffering on an individual level and therefore serves as a win-win situation for everyone. Despite the multitude of benefits of promoting good mental health, most workplaces in Nigeria do very little to prevent mental ill health or to address emotional wellbeing.

Here are three ways in which employers can promote good mental health in the workplace:

Create a healthy environment
While biology is certainly a factor in the development of mental illness, the environment also plays a large role. It’s important for employers to take a look at the lifestyle they’re promoting among their employees. Expecting employees to work 80+ hours a week or insisting people respond to work-related email from home are just a few of the things that can interfere with an employee’s ability to build a natural buffer against work-related stress.

Since most people spend approximately one-third of their time at work, it is important to ensure the workplace is taking steps to promote good health. A few simple ways to foster a healthy environment include encouraging exercise, allowing for breaks where employees can socialize, and offering stress reduction workshops. Hiring a mental health professional to teach mindfulness or offering free access to a yoga class are just a few creative ways to boost mental strength and develop resilience to mental ill health.

Help employees identify mental health risks
Approximately one in four adults will experience a mental illness in any given year. Yet, many of them suffer in silence. Some people fail to recognize they’re experiencing a mental health issue. Instead, they may associate their symptoms with ageing or assume that their problems are just a normal part of stress. Helping employees recognize their risk factors and symptoms is one of the simplest yet most effective ways for employers to help.

There are several ways in which organizations can allow employees to access confidential mental health screenings. One way is to invite a mental health professional into the organization to provide free screenings. If this screening reveals a high likelihood to mental health difficulties, they can be referred for a complete assessment. Screenings can be completed in complete privacy and employees can be given immediate feedback about their results, as well as information and support in accessing services.

Assist employees in addressing mental ill health
Mental illness is very treatable, so it’s essential that employees are supported in their attempts to seek help. Allowing an employee to attend weekly therapy appointments during business hours or with an in-house therapist could prevent that employee from having to go on sick leave due to serious depression. Creating policies that support emotional wellbeing and treatment can ensure that employees are able to perform at their best.

While most employers would never step over an employee suffering a serious physical health problem (such as a stroke or a heart attack), employees who are clearly experiencing a mental health problem are often ignored. Unfortunately, ignoring mental health only furthers the stigma. Educating managers on how to address employee mental health can ensure that employees feel safe to talk about their concerns and it will increase the likelihood that they’ll access available resources.

Dr Ukwuori-Gisela Kalu is a Clinical Psychologist who is passionate about Mental Health promotion and intervention in Nigeria. She works as a Consultant Clinical Psychologist in Private Practice in both Lagos and Abuja. Dr Ukwuori-Gisela Kalu offers psychological therapy to individuals and couples, as well as corporate services to businesses. She has valuable experience working therapeutically in a range of evidence-based psychological approaches (e.g. Cognitive-Behavioural Therapy, Narrative Exposure Therapy, Behavioural Couples Therapy, Interpersonal Psychotherapy, Mindfulness Based Cognitive Therapy) and with a wide range of clientele (including children, adolescence, individuals with Neuro-developmental disorders such as Autism Spectrum Disorder, individuals with intellectual disabilities, older adults and adults of working age).