Psychiatry in Nigeria

Abstract

Nigeria is a huge country. It covers an area of 924 000 km² on the west coast of Africa. It has a population of about 110 million, which means that every one in six Africans is a Nigerian. It is a country of diverse ethnicity, with over 200 spoken languages, even though three of those are spoken by about 60% of the population. Administratively, it is divided into 36 states and operates a federal system of government, with constitutional responsibilities allocated to the various tiers of government – central, state and local. There are two main religions, Islam (predominantly in the north) and Christianity (predominantly in the south). However, a large proportion of the people still practise traditional religions exclusively or in addition to either Islam or Christianity.

In spite of its abundant natural and human resources, Nigeria is still a poor country, and nowhere is that status indicated better than in its health indices.

In spite of its abundant natural and human resources, Nigeria is still a poor country, and nowhere is that status indicated better than in its health indices. About 170 out of every 1000 children die before the age of 5 years and life expectancy is 46.8 years for men and 48.2 years for women (World Health Organization, 2000). It spends about 3% of its gross domestic product on health (World Health Organization, 2001) and in a rating of the overall health performance of all 191 member states of the World Health Organization in 2000, Nigeria was ranked 187 (World Health Organization, 2000).

A brief history

Available records suggest that the first asylum had been established in the southern city of Calabar by 1904. It was followed by the Yaba asylum, also in the south, which was opened in 1907 with 48 patients. Before that, some patients with mental illness were sent to Sierra Leone. However, the seeking of orthodox care for mental illness must have been very uncommon at the time, for a British army physician claimed in 1845 that insanity was rare in Nigeria (Anumonye, 1976). The asylums relied on the services of general medical officers, since there were no psychiatrists and those there were provided essentially custodial management.

When the Aro Mental Hospital was opened in Abeokuta in 1954, it was to respond to the need for improved mental health care identified by the British colonial government. Since Dr Thomas Adeoye Lambo had arrived back in the country from England in 1952, the establishment of Aro Mental Hospital was also an opportunity to make the best use of the services of this first Nigerian psychiatrist. The hospital, later to be known as the Aro Neuropsychiatric Hospital, was to play a central role in the development of psychiatry in Nigeria (Asuni, 1967, 1972)

Clinical practice

From a total of 5 in 1963, 25 in 1975 and 35 in 1981, today there are about 100 psychiatrists working in Nigeria (Jegede, 1981). Most of these are based in departments of psychiatry in the 12 medical schools and the eight psychiatric hospitals in the country. The provision of psychiatric beds amounts to about 0.4 per 10 000 persons, while that of both psychologists and social workers is 0.02 per 100 000 persons (World Health Organization, 2001). Thus, the country is severely underserved in these respects. Psychiatric care is almost entirely located within the public health sector – there is virtually no private psychiatric practice in the country. Since the available resources are also all located in urban centres and predominantly in the southern parts of the country, some sections of the community experience an even worse shortage of resources than others.

Traditional antipsychotic drugs and tricyclic antidepressants are available and relatively affordable. However, the newer formulations are either unavailable or too expensive for most of those in need. For example, a month’s supply of risperidone would cost more than twice the minimum monthly wage in the public service.

Traditional healing practices and faith healing, much of which are poorly understood and some of which are quite clearly harmful, are the common resort. The lay view of mental illness is generally still rooted in supernatural beliefs; moreover, given the restricted access to adequate orthodox psychiatric care, few members of the public get even a chance to be convinced of its effectiveness.

Training

The first generation of Nigerian psychiatrists – those who trained in the early 1960s – received their training almost exclusively in England or Scotland. Most started off with an introduction to the field in Nigeria and, with encouragement and support from Dr Lambo, completed their training in the UK. In later years, Nigerian psychiatrists also trained in places such as North America and Australia (Jegede, 1981).

Most of the psychiatrists currently working in the country received their training locally. The West African Postgraduate Medical College, part of the West African Health Community, was constituted in 1976. Incorporating Anglophone countries in the West African sub-region (i.e. Nigeria, Ghana, Liberia, Sierra Leone and Gambia), it regulates and conducts postgraduate diploma examinations (termed ‘fellowship’ examinations) for specialist qualifications. Soon after its inauguration, the West African Postgraduate Medical College was complemented by the National Postgraduate Medical College, which was established by a Nigerian government decree in 1979. The Faculties of Psychiatry of both Colleges run broadly similar courses of training that span a minimum of 4 years. The examinations are conducted in three stages: primary (mainly basic sciences and psychology), part I (consisting of clinical, written and oral examinations) and part II (consisting a supervised research project, the results of which are reported in a bound dissertation and a viva). In practice, the average time taken to complete training is 5 years.

Traditional antipsychotic drugs and tricyclic antidepressants are … affordable. However, the newer formulations are either unavailable or are too expensive for most of those in need … a month’s supply of risperidone would cost more than twice the minimum monthly wage in the public service.

Traditionally, attracting doctors to psychiatry had been difficult. Poor conditions of service in the public sector made it unattractive and led doctors to seek specialisation in areas where lucrative private practice could be expected. Psychiatry was and is still not one of these. However, with the recent improvement in the conditions of service for doctors in the public health service, the number of doctors wishing to specialise in psychiatry has increased dramatically in the past few years. Currently, there are about 110 doctors at various stages of training. Whether improved service conditions will also translate into better retention of psychiatrists in the country is not yet clear. Many trainee psychiatrists have obtained training positions overseas (particularly in the UK) in the past and have not shown a willingness to return home to practise after qualifying.

Research

The contribution of Nigerian psychiatrists to the international psychiatric literature contrasts with their small number on the ground and the general lack of institutionalised support for research in the country. Nigerian psychiatry is known to many for the influential work of Dr Lambo on the Aro village treatment system and his pioneering community epidemiological study (Leighton et al, 1963). It is also known for its involvement in such landmark studies as the International Pilot Study of Schizophrenia, the 10-country study of the incidence and manifestations of schizophrenia and, more recently, the Psychological Problems in General Health Care project.

Part of the reason for this is the strong academic orientation of Nigerian psychiatry, with most professionals working at some point in their careers in universities. However, beyond these remarkable achievements, the range of research activities is actually relatively narrow. Most are small-scale surveys and descriptive clinical studies. Many of these address subjects such as drug use in schools and phenomenological studies of psychoses, among others. Intervention studies are rare and cohort studies few. Research addressing special groups such as children and the elderly is very much in its infancy.

Mental health policy

The first mental health policy for the country was launched in 1991 (Federal Ministry of Health, 1991). Its laudable 14 declarations include:

The Association of Psychiatrists in Nigeria, formed in 1969 at a meeting in Ibadan attended by seven members, has grown such that there are now over 130 members and associate members. Its annual general and scientific meeting has become an established annual event.

The mental health policy shall be based on the national philosophy of social justice and equity.

Individuals with mental, neurological and psychological disorders shall have the same rights to treatment and support as those with physical illness and shall be treated in health facilities as close as possible to their own community. No person shall suffer discrimination on account of mental illness.

It also recommends a revision of laws relating to the mentally ill in Nigerian statutes. The policy is backed with a National Mental Health Programme and Action Plan, which, unfortunately, has hardly been implemented.

The legal provisions in the Nigerian statutes are obsolete. For example, the country still operates within the framework of the Lunacy Act Cap. 112 (Cap. 81 Lagos) of 1916, which in turn was based on the Lunacy Acts 1890–1908 of the United Kingdom. Accordingly, the Act recommends certification for ‘lunatics’, including ‘an idiot or any person of unsound mind’. These provisions fail to recognise the present-day view of severe mental disorders as treatable conditions, or to give special consideration for actions that breach the laws of the land but that are committed when the individual is unable to make a reasoned judgement. However, there is some hope that, in the new democratic political dispensation, there may be some positive changes, as attempts at revising these laws are currently under way.

Professional groups

The Association of Psychiatrists in Nigeria, formed in 1969 at a meeting in Ibadan attended by seven members, has grown such that there are now over 130 members and associate members. Its annual general and scientific meeting has become an established annual event. The Association was a strong member of the now defunct African Psychiatric Association. Several of its members were also instrumental in the formation and nurturing of the African Journal of Psychiatry, which, unfortunately, is also now defunct. Indeed, the involvement of Nigerian psychiatrists in international professional associations started with the organisation in 1961 of the first Pan-African Psychiatric Conference by Dr Lambo. Participants at the conference had come from several African countries, as well as Europe and North America. Currently, Nigerian psychiatrists are fully involved in the activities of the World Psychiatric Association and newly established Association of African Psychiatrists and Allied Workers.

Several Nigerian psychiatrists are members or fellows of the Royal College of Psychiatrists. At present, there is no organised forum for them in which to meet and deliberate on College affairs, even though Nigerian members and fellows are often present at the annual College conference. The story is different for Nigerian psychiatrists working in the UK. Several of these have played active roles in the activities of the College and some have held important leadership positions in training and examination programmes.