Nigeria is a country with an approximate area of 924 thousand sq. km. (UNO, 2001). Its population is 127.117 million, and the sex ratio (men per hundred women) is 102 (UNO, 2004). The proportion of population under the age of 15 years is 44% (UNO, 2004), and the proportion of population above the age of 60 years is 5% (WHO, 2004). The literacy rate is 74.4% for men and 59.4% for women (UNESCO/MoH, 2004).
The country is a low income group country (based on World Bank 2004 criteria). The proportion of health budget to GDP is 3.4%. The per capita total expenditure on health is 31 international $, and the per capita government expenditure on health is 7 international $ (WHO, 2004). The main language(s) used in the country is (are) English, Hausa, Yoruba, Igbo and Pidgin English. The largest ethnic group(s) is (are) Hausa and Fulani in the north, Yoruba in the southwest and Igbo in the southeast., and the other ethnic group(s) are (is) Efik/Ibibio, Tiv, Ijaw, Kanuri, Nupe, Edo and Idoma. The largest religious group(s) is (are) Muslim and Christian, and the other religious group(s) are (is) indigenous groups. The life expectancy at birth is 48 years for males and 49.6 years for females (WHO, 2004). The healthy life expectancy at birth is 41 years for males and 42 years for females (WHO, 2004).
Leighton et al (1963) conducted a cross-cultural study in which they found that subjects in Yorubaland, Nigeria had more mental symptoms especially those related to the organic domain but fewer cases of mental disorders in comparison to those in the Stirling County in North America. More men in the former setting and more women in the latter setting had mental disorders. Gureje et al (1992a) assessed 787 primary care patients using the Yoruba translation of the General Health Questionnaire (GHQ–12) and Composite International Diagnostic Interview (CIDI) in a two stage design. A weighted prevalence for specific DSM-III-R disorders was 27.8%. Abiodun (1993) assessed 272 primary care patients using a two-stage procedure with GHQ-12 and the Present State Examination Schedule (PSE). The prevalence of psychiatric disorder was 21.3%. Depressive neurosis (51.7%) and anxiety neurosis (36.3%) were common. Psychiatric morbidity was associated with age (older), gender (female) and marital status (widowed, separated or divorced). Gureje (2002) assessed 704 primary care patients with GHQ-28, a structured diagnostic interview and a disability assessment schedule, at 2 time points one year apart. About 10% met the ICD-10 criteria for any disorder and 25% met GHQ caseness criterion. Being a case on the GHQ at baseline (but not on ICD-10) was associated with disability at 12-month follow-up. Uwakwe (2000) assessed 164 rural community subjects aged above 60 years using the Self-Reporting Questionnaire and the Geriatric Mental State Schedule. Psychiatric diagnoses as per ICD-10 Research Criteria were recorded in 23.1% of the subjects, with depression constituting 79% of all diagnoses. Hendrie et al (2001) and Ogunniyi et al (2000) examined two elderly (65+ years) community-dwelling populations in USA (n=2147 African Americans) and Nigeria (n=2459) following a two stage procedure. The age-standardized annual incidence rates were significantly lower among the Nigerians (Dementia: 1.4%, Alzheimer’s disease: 1.2%) compared to the African Americans (Dementia: 3.2%, Alzheimer’s disease: 2.5%). The overall age-adjusted prevalence rates of dementia and Alzheimer’s disease in Ibadan (2.3% and 1.4%, respectively) were also lower than the respective values (8.2% and 6.2%) obtained for African Americans. In Nigeria, dementia was associated with old age and female gender. The frequencies of the vascular risk factors were lower in Nigerians. In the same sample, Perkins et al (2002) found that dementia was associated with increased mortality at both sites (Ibadan RR = 2.83, Indianapolis RR = 2.05). Obot (1990) conducted a household survey (n=1271) and found that 22.6% of adults smoked regularly. Abiodun et al (1994) examined 1041 secondary school students using a 117-item WHO self-report substance-use questionnaire. Use of salicylates (56.2%), stimulants (21.6%), alcohol (12.0%) and cigarettes (4.4%) was common. Adelekan and Ndom (1997) evaluated more than 1800 secondary school students with the same instrument at two time points 5 years apart. On the whole, substance use was less frequent in the follow-up sample. However, there were significant increases in the current use of cocaine, organic solvents and hallucinogens. Mamman et al (2002) examined 300 women from rural/suburban areas and found that 64% of them used alcohol, with more than half reporting current use. Gureje et al (1992b) administered the GHQ-12, the Alcohol Use Disorders Identification Test (AUDIT) and the Composite International Diagnostic Interview (CIDI) to subjects in an urban primary care clinic. Alcohol abuse or dependence according to DSM-III-R was estimated to be present in 1.7%. The National Expert Committee on Non-Communicable Diseases (1997) reported that 8.9% of adults (n=16 019) smoked cigarettes. Smoking was associated with gender (male), age (25-34 years) and residence (urban). Also more urban males drank alcohol in comparison to rural males. The National HIV/AIDS and Reproductive Health Survey (2003) showed that 12% of adults (n=10 910) had consumed alcoholic beverages regularly in the past 4 weeks and 3% drank daily. Use of psychoactive drugs was reported by 1% of the population. Jablensky et al (1992) reported the findings of the Determinants of Outcome of Severe Mental Disorders (DOSMED) study. They found that schizophrenia had similar presentation and incidence rates across different countries, but a better outcome in developing countries. Aderibigbe et al (1993) examined 162 women during second trimester and 6-8 weeks postpartum using GHQ-28 and PAS. The rate of caseness was 30% at the prenatal assessment and 14% in the postnatal assessment. Marital and family problems were associated with morbidity. Ohaeri and Odejide (1994) evaluated 865 adults from primary care clinics using GHQ-28, the Self-Reporting Questionnaire (SRQ) and the Brief Disability Questionnaire. About 8.2% fulfilled criteria for probable somatoform disorders. Nwosu and Odesanmi (2001) reviewed autopsy records and reported that the rate of completed suicide was 0.4 per 100 000 population with a male to female ratio of 3.6 to 1. The majority of the victims were in the third decade of life and the common methods of committing suicide were consumption of insecticides and use of firearms. Eferakeya (1984) reviewed records of attempted suicides. The incidence of suicide attempt was 7/100 000. The majority of attempters was below 30 years of age and used poisons (88%). Mental illnesses were reported in one-third of the sample. Abiodun (1992) examined 500 rural children aged between 5-15 years and found the prevalence of psychiatric morbidity to be 15%, with emotional and conduct disorders present in two-thirds of these subjects. Children from disrupted families were more likely to suffer from psychiatric morbidity. Adelekan et al (1999) administered the Rutter’s A2 scale to parents of 846 primary school children. The criterion of caseness (cut-off of 13) was met by 18.6% (neurotic disorders: 7.3%, anti-social disorders: 8% and undifferentiated disorders: 3.3%) being common. Psychiatric morbidity was associated with gender (boys), physical and emotional problems during pregnancy in mothers, delayed developmental milestones, major illness during childhood, broken homes and attending rural schools. Gureje et al (1994) assessed 227 children (7-14 years) attending a primary care centre with the children’s version of the Schedule for Affective Disorders and Schizophrenia. The weighted prevalence of any DSM-III-R disorders was 19.6% (depressive disorders: 6%, anxiety disorders: 4.7% and conduct disorders: 6.1%).
MENTAL HEALTH RESOURCES
Mental Health Policy A mental health policy is present. The policy was initially formulated in 1991. The components of the policy are advocacy, promotion, prevention, treatment and rehabilitation. Training and research and management information system are also emphasized in the policy.
Substance Abuse Policy A substance abuse policy is present. The policy was initially formulated in 1990. National Drug Law Enforcement Agency Decree No. 48 was amended in 1990.
National Mental Health Programme A national mental health programme is present. The programme was formulated in 1989. It was adopted in 1991.
National Therapeutic Drug Policy/Essential List of Drugs A national therapeutic drug policy/essential list of drugs is present. It was formulated in 1991. Psychotropics are available and relatively affordable. However, newer formulations are either unavailable or too expensive. For example, a month’s supply of risperidone (2mg) would cost more than the minimum monthly wage in the public service.
Mental Health Legislation The existing legislation on mental health dates back to 1916, later adopted as the Lunacy Act CAP 112, Laws of the Federation of Nigeria, 1958. A revised Mental Health Bill is now before the National Assembly (Parliament) for inaction into law. In 2004, it had passed a public hearing stage and adoption by the Senate. It is now before the House of Representatives. The latest legislation was enacted in 1958.
Mental Health Financing There are budget allocations for mental health. Details about expenditure on mental health are not available. The primary sources of mental health financing in descending order are out of pocket expenditure by the patient or family, tax based, grants, social insurance and private insurances. The country does not have disability benefits for persons with mental disorders.
Mental Health Facilities Mental health is a part of primary health care system. Actual treatment of severe mental disorders is available at the primary level. However, relatively few centres have trained staff and equipment to implement primary health care. Regular training of primary care professionals is carried out in the field of mental health. Each state has a school of Health Technologists for training of primary care professionals including health care workers. There are community care facilities for patients with mental disorders. Community care is available in a few states. Providers include private medical practitioners, NGOs, especially faith-based organizations, and traditional healers.
Psychiatric Beds and Professionals
psychiatric beds per 10 000 population
beds in mental hospitals per 10 000 population
beds in general hospitals per 10 000 population
beds in other settings per 10 000 population
- Number of
psychiatrists per 100 000 population
- Number of
neurosurgeons per 100 000 population
- Number of
psychiatric nurses per 100 000 population
- Number of
neurologists per 100 000 population
- Number of
psychologists per 100 000 population
- Number of social workers per
100 000 population
Many health professionals migrate to industrialized countries leading to a shortage of personnel. Most resources are located in urban centres and predominantly in the southern parts of the country. There is virtually no private practice in the country. Many psychiatrists who have trained in other countries have not returned.
Non-Governmental Organizations NGOs are involved with mental health in the country. They are mainly involved in advocacy, promotion, prevention, treatment and rehabilitation.
Information Gathering System There is mental health reporting system in the country. Mental health morbidity statistics are available in each mental health institution but not always aggregated comprehensively at the national level.
The country has data collection system or epidemiological study on mental health. A national survey of mental health and wellbeing conducted in 2003-2004 to provide information on the size and extent of mental health problems in the country is undergoing analysis.
Programmes for Special Population The country has specific programmes for mental health for refugees, disaster affected population, elderly and children. There is a National Emergency Relief Agency (NEMA) that caters for the needs of refugees and populations affected by disasters. Mental health workers are invited to render necessary assistance, whenever required. Specific programmes have been developed for substance use disorders.
Therapeutic Drugs The following therapeutic drugs are generally available at the primary health care level of the country: carbamazepine, phenobarbital, phenytoin sodium, amitriptyline, chlorpromazine, diazepam, fluphenazine, haloperidol, biperiden. Benzhexol (5mg) is available.Other Information
Many psychiatric researches have been directed to problems related to the scientific practice and acceptability of psychiatry as a distinct discipline of medicine. These research studies created a positive awareness which led to the establishment of more psychiatry units in the general hospital setting, several specialist psychiatric institutions in the community and psychiatric residency programmes in the country.