Mental illnesses such as depression and anxiety are highly rampant in low‐ and middle‐income countries like Nigeria. People in Nigeria lack adequate knowledge regarding mental health disorders and have various misconceptions for its underlying causes such as drug and alcohol use (80.8%), possession by evil spirits (30.2%), traumatic event or shock (29.9%), stress (29.2%), and genetic inheritance (26.5%), and very few people believe that biological factors or brain diseases are the underlying cause of the development of these disorders.
There is no local, authentic data regarding mental illness prevalence in the Nigerian community and reports show very low prevalence for depressive and anxiety disorders (3.1% lifetime depression, 5.7% lifetime anxiety), leading to exclusion of data from national WMHS (World Mental Health Survey) epidemiology reports. All this eventually resulted in failure of gaining much attention at the local and international levels towards this serious issue and has become more critical, especially amidst the COVID‐19 pandemic.
A study reported that the most common depressive symptoms among depressed patients in Nigeria were anhedonia 9.1%, suicidal ideation 7.3%, hopelessness 6.9% and 1.8% psychomotor retardation. Similarly, generalized anxiety disorder patients reported worrying too much about different things (12.3%), easily annoyed (11.1%) and inability to control worrying (7.3%). Stigmatizing behaviour towards mentally ill people is very well documented in Nigeria, which is prevalent among all the classes and categories of the society. This behaviour negatively affects the patient’s quality of life as well as creates a barrier in accessing mental health care, apart from spreading misconceptions regarding the causes of mental illnesses in the community.
Despite these huge numbers of mental health cases in the country, Nigeria can only boast of 250 psychiatrists and another 200 psychiatry trainees in its 45 government-owned mental health facilities scattered across the country. If the available 250 psychiatrists are spread evenly over the 45 mental health facilities to treat 50 million people currently with mental ailments in the country, each facility will have 6 psychiatrists to attend to at least 1.1 million waiting patients! This shortage of mental health personnel is the second limitation against anyone who struggles with some mental condition in Nigeria.
The scarcity of psychiatrists is a corollary of the gross shortages in the number of facilities for them to practice. Going by the huge costs of qualifying as a specialist in psychiatry, no one wants to graduate with little or no place for them to work.
Nigeria’s mental health legislation was first enacted in 1916 and was called the Lunacy Ordinance. In 1958, these laws were amended to give medical practitioners and magistrates the power to detain an individual suffering from mental illness.1 Renamed the Lunacy Act of 1958, these laws have not been amended since.
In 2003, a Mental Health Bill was put forward to the National Assembly of Nigeria. With little support and no progress for more than 6 years, it was withdrawn in April, 2009. This Bill was presented again in 2013, when the National Policy for Mental Health Services Delivery set out the principles for the delivery of care to people with mental, neurological, and substance abuse problems.
As of 2019, the Senate passed the bill after a second reading and held a public hearing in 2020. On November 28, 2022, the two chambers of the National Assembly passed the National Mental Health Bill, 2021 and forwarded it to President Buhari for consideration and assent. President Muhammadu Buhari finally signed into law the Mental Health Bill harmonised by both Houses of Assembly in 2021.
In a huge change to mental health care in the country, the law establishes a National Council for Mental Health and Substance Abuse Services, which is tasked with promoting good mental health and facilitating the provision of humane care, including treatment and rehabilitation. The council has the power to set and enforce standards of care.
A Mental Health Review Tribunal will be responsible for protecting patients’ interests, providing guidance on minimising intrusive and irreversible treatments, such as seclusion or restraint. It will also ensure that informed consent and approval is obtained for intrusive or irreversible treatments. The law’s Section 24 codifies the rights of people in need of mental health services. It provides funding for mental health care, and outlines a path for integrating mental health services into primary care at the local government level. It also prohibits discrimination and stigmatisation of individuals living with mental illnesses.
The legislation is the country’s first reform on mental health since independence. The old law, in place since 1916 and reviewed in 1968, was criticised for being out-dated and reflective of a time when mental health was misunderstood and the treatment of those with mental health needs was inhumane and ineffective. Under the old law, attempting suicide was a criminal act punishable with imprisonment.
Previous attempts at national mental health reform in 2003 and 2013 failed in Nigeria, but the National Assembly passed the National Mental Health Bill 2020 in 2021. It has taken 2 years for President Buhari to sign it into law.
Now, there is a need to establish more training institutions for different health care professionals to increase the workforce of psychiatry and mental health support professionals. There should also be routine public enlightenment, outreach, training programmes and supervisory visits by specialists to support other healthcare facilities in identifying mental health disorders and referring them to appropriate care centres accordingly. Professional organizations such as Association of Psychiatrist and Nigeria Medical Association (NMA) can provide free-outreach and tailored training programs to general physicians and nurses on mental health care skills.
Okeke writes from the Centre for Social Justice (CSJ) Nigeria
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