“Do you know that there’s only one psychiatrist in the whole of Imo State?” — This was a line in a post published by Onyekachi Onumara on his Facebook page on the 29th of August 2023. As expected, the post, which he closed with the hashtag #MentalHealthGap, attracted several responses, with many saying it was inaccurate. In the comments, someone gave the address of a clinic in the State with a consultant psychiatrist. When Onumara asked for the consultant’s name, it turned out to be the same person he had in mind when he initially made the assertion in his Facebook post, Dr Chinyere M. Aguocha.
Mental health conditions contribute significantly to poor health outcomes, human rights violations, and global and national economic loss. According to the World Health Organisation (WHO), mental health conditions such as depression and anxiety disorders cost the global economy USD 1 trillion, annually. Undiagnosed cases can worsen this situation, especially in small communities within countries like Nigeria, where mental health myths and misconceptions are still common.
Besides the economic effects, untreated mental health illnesses have social and economic impacts on patients, their caregivers and their communities. However, interventions that equip non-specialist healthcare workers can help address gaps by equipping them with skills to support the diagnosis and management of cases.
Maximising resources
Currently, there is a global shortage of psychiatrists to diagnose, treat, and manage patients with mental health conditions, and Nigeria is no exception. However, we have some resources that are not adequately leveraged. Even though there are still gaps, “the primary healthcare (PHC) system is structured to be present in every political ward,” said Dr. Theddeus Iheanacho, assistant professor of psychiatry at Yale University in the United States. Also, there is a national health policy document that seeks to integrate mental healthcare into basic healthcare provision at the community level and the Mental Health Gap Action Programme (mhGAP) by the WHO, he explained. The mhGAP is an “intervention guide that shows you how to train non-specialists in mental health to render basic mental health care in the communities. And then make a referral or consultation with specialists as needed,” Iheanacho noted. There is already some evidence pointing to the feasibility of using it to scale up mental health services globally, including in Osun and Ogun States in Nigeria. With a team of collaborators and partners, Iheanacho designed the Health Action for Psychiatric Problems in Nigeria, including Epilepsy and Substances (HAPPINESS) project to use the mhGAP to improve access to mental healthcare in the state.
Adapting for Happiness
The HAPPINESS project leveraged existing structures to make mental healthcare more accessible. Iheanacho said that the spirit of the project is guided by a local adage that says every village has enough firewood to serve its inhabitants. For him, the mhGAP and PHC structures across the state, already being utilised to deliver vaccination, antenatal and health promotion campaigns, served this purpose. He noted there was only one state-hired psychiatrist when he started the project in 2018, giving some credence to Onumara’s post.
In simple terms, the project used WHO’s mhGAP manual to train community health workers, nurses and even medical doctors supporting PHCs to integrate mental health services into primary care. They could assess, screen, treat, and then make referrals to specialists as needed, Iheanacho explained. However, another critical element, he added, is using technology “to connect them to psychiatrists who are in Nigeria, but also Nigerian psychiatrists who are abroad”. They used WhatsApp and Skype when the project started in 2018 before the pandemic popularised Zoom. These specialists help provide continued education, supervision, collaboration, and consultation to the trained health workers. They currently have 12 of them, four of which are in Nigeria. An online directory showing health facility locations and contact details of the trained health workers also contributed to increasing access to care.
However, before starting the project, they engaged with the state, which involved the State Primary Health Care Development Agency (SPHCDA), the Honourable Commissioner for Health and the state’s only psychiatrist to understand how they respond to mental health and the structures in place, especially available human resources. Following this engagement and needs assessment, they proposed the HAPPINESS initiative but, they had to adapt the mhGAP for context. “For instance, the mhGAP tells you to assess someone for substance use problems, say too much alcohol. How do you do that since the tool is developed for use across different parts of the world,” Iheanacho said. So, adapting involved determining any local names for alcohol for example and quantifying what amount equates to the volume used in the mhGAP.
What’s Working
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They also had to translate some parts of the tool to Igbo language to improve understanding. Out of the over ten modules in the tool, they selected the conditions identified to be more common during their needs assessment and training. They prioritised depression, psychosis, substance use, suicide, and child and adolescent mental health. The training is followed by community sensitisation for demand generation. Churches, traditional rulers, and the women’s August meeting, common in the southeast, were leveraged to create awareness. They also used radio programs to sensitise more people in the area.
Part of earlier engagements with key state actors involved ensuring that the Drug Revolving Fund (DRF) provided affordable, and consistently available medications for managing mental health challenges. This was done to prevent stock-outs when patients visit health facilities.
The project started as a collaboration between Yale’s Department of Psychiatry, Yale’s School of Medicine, and Imo State University’s Teaching Hospital, and is supported by the Yale Global Mental Health Program, CBM International, the Imo State Primary Health Care Development Agency, and Imo State Government. So far, over 100 health professionals across primary and secondary health facilities have benefitted from the training.
Adaptive listening
Amarachi Ibeawuchi, a nurse attached to the Osu PHC in Isiala Mbano Local Government Area (LGA), said the training made her more empathetic when dealing with patients. “There have been situations where patients go through laboratory tests for malaria or typhoid and we find nothing,” but engaging with them using lessons from the training, she found that they are dealing with problems that affect their sleeping and eating patterns. By offering them psychotherapy, their conditions improved, and some came back to thank her. Even though she learned about mental health in school before her practice started 13 years ago, she said the mhGAP training provided her practical insights on how to help patients. It also encouraged her to start learning more about postpartum depression.
Having health workers in various locations across the state means patients can easily connect with service providers. The experience of a young man on antidepressant medication who returned from South Africa just before the COVID-19 lockdown is a good example. His family reached out to Iheanacho, and he helped fill his prescription with a similar and equally effective medication by helping them contact one of the trained health workers.
Iheanacho noted that one of the key success factors of the project was learning to listen, especially as someone coming from outside the country to implement an intervention. “It’s good to listen to people who live in Nigeria and grasp what a solution could look like for them,” he said. While engaging with some healthcare workers about the project plans, they told him some facilities were in bad shape and would not inspire patients to visit. This led them to carry out minor renovations to improve the facilities.
Sustaining what works
While the project team observed a general inability of people to pay for care, (as low as N1000 for medications), Iheanacho said their experience revealed there are Nigerians in the diaspora willing to pay for mental health services for relatives back home if they are assured of quality services. However, he also noted that a more sustainable way for more people to have access is government involvement. “One of the things I would say would be to utilise the mechanism of the state insurance schemes to include mental health. Because right now, mental health is not part of the state insurance schemes,” he said.
Beyond the inability to pay, misinformation, stigma, inadequate funding, and lack of access roads to clinics were some barriers to mental health care integration. But with collaboration and partnerships, it is possible to “move the needle”. The team is looking to partner with more religious institutions that provide emotional and mental health support, albeit informally. But one of the sustainable ways to ensure more people have the skills to support mental healthcare provision is by ensuring the trainings advance from being five-day long trainings to being offered by academic institutions as Diploma or Post-Graduate Diploma (PGD) Programmes, says Dr Ijeoma Ibe who provides local support and partnership engagements for the project. “We have proposals with the Owerri Catholic Archdiocese. We are also engaging with the Federal University of Technology Owerri and Imo State University to introduce mental health as Diploma and PGD programs,” she said.
One of the objectives of Nigeria’s 2023 Mental Health Act is to facilitate the adoption of a community-based approach to the provision of mental health care services. The government needs to work with initiatives already integrating mental health care in PHCs. By being more involved, the government will also provide the essential regulatory function of ensuring trained health workers do not overstep their boundaries, as quackery is already a challenge.