Provision of mental health services in Nigeria.

Nigeria, like other African countries, is short of personnel trained in mental healthcare. Efforts to tackle the problem have often focused on increasing the numbers of psychiatrists and nurses in the field. These efforts, over the past 20 years, have not appeared to have greatly improved service delivery at the grass roots. Most of the specialist centres where such highly trained personnel work are in urban areas and for a large part of the population access to them is limited by distance and cost.

Mental healthcare is one of the recognised elements of primary healthcare in Nigeria. Primary health centres (PHCs) are supposed to have a reasonable amount of competence in recognising and dealing with some of the more common mental disorders. They are the first point of contact for many individuals and serve as the first link in the referral system. The population ratio of psychiatrists is 0.4:100 000, while for psychiatric nurses it is 4:100 000 (World Health Organization, 2001).

In this paper we describe two audits in Lagos State undertaken (as part of a larger survey of core personnel and facilities available for psychiatric services) to evaluate the use of non-specialist resources, specifically PHCs and general practitioners (GPs), potentially available for the provision of mental healthcare, and examine their present state of functioning and participation in it. Insights are derived about how they could be harnessed to provide more effective coverage for mental healthcare.

Methods

The audit of PHCs focused on available personnel and physical resources (drugs and equipment) relevant to the care of people with mental illness. An evaluation of the knowledge base and attitudes of the identified personnel in these centres, as they pertain to mental illness, was conducted using specially designed questionnaires. These instruments were pre-tested in five pre-selected PHCs, and were found to be appropriate and adequate. Five of the 20 local government areas of the state were randomly selected. Within each area, three PHCs were randomly selected for assessment. Thus a total of 15 PHCs were included in the study. These centres together had a total of 73 personnel, who were all included in the survey.

The knowledge base and attitudes of GPs as well as appropriate physical resources (drugs and equipment) available in their respective clinics as they pertain to the treatment of mental illness were also audited, using another specially designed questionnaire. This instrument was pre-tested on 10 GPs and was similarly found to be adequate and appropriate.

Items in the questionnaires used for both the PHC and GP surveys were independently scored by two experts (both psychiatrists). Four core questions in the PHC instrument (Table 1) and three core questions in the GP study (Table 2) were rated by these two experts on a five-point scale (0 indicating no knowledge and 4 indicating very good knowledge). The mean of the scores assigned by the two experts for each response was given as the response score for each participant in the study. Composite scores for each participant were also computed to reflect overall knowledge and attitude. The expert inter-rater correlation (Pearson product–moment) was significant (for the PHC survey, n = 73, correlation coefficient = 0.70, P < 0.001).

Table 1

Knowledge and attitude ratings of the PHC personnel

Item	Mean	s.d.	Range
Knowledge of definition of mental disorder	1.41	0.65	0–3
Knowledge of categories of mental illnesses	1.32	0.76	0–3
Understanding of causation	1.57	0.63	0–3
Knowledge of treatment modalities	1.16	0.69	0–3
Overall rating	1.39	0.49	0–2.88

Expert ratings of knowledge and attitude, where 0 = no knowledge and 4 = very good knowledge. A generally poor level of knowledge regarding mental illness, its manifestations and management emerged across all categories.

Table 2

Knowledge and attitude ratings of the GPs

Item	Mean	s.d.	Range
Knowledge of basic classification	1.49	1.19	0–4
Diagnostic ability	1.39	0.95	0–3.5
Management	1.04	1.05	0–3
Overall rating	1.32	0.90	0–3.33

Expert ratings of knowledge and attitude, where 0 = no knowledge and 4 = very good knowledge. A generally poor level of knowledge across all levels emerged. Knowledge of basic classification was rated highest, while management knowledge was the poorest.

Results

Audit of PHCs

A general finding was that none of the PHCs surveyed had any stock of psychotropic drugs in its pharmacy.

The 73 staff in the PHCs comprised the following professional categories:

21 nurses (29% of the sample)

18 community health workers (25%)

15 community health extension workers (20%)

8 administrative officers (11%)

6 pharmacy technicians (8%)

5 cleaners (7%).

There were no doctors working in the PHCs at the time of the survey. The core clinical functions were carried out by nurses, community health workers and community health extension workers. These three categories also formed the bulk of the workforce. Pharmacy technicians provided technical support.

The expert ratings of the knowledge and attitudes of these staff are summarised in Table 1. More than half the personnel had had at least graduate-level education; three (4%) were postgraduates. Most of the remaining staff had completed their secondary education, although five (7%) had received only primary education.

Audit of GPs

General practitioners from all across Lagos State were surveyed. The venue of the survey was the meeting of the Association of General Medical Practitioners. Of the 51 surveyed, one failed to return the questionnaire. Fifty participants thus were included in the study.

Most of the GPs (44 out of 50) saw psychiatric patients in their practices, but this left a sizeable number (6) who did not see psychiatric patients at all. Moreover, only 30 (60%) of the practitioners actually treated patients for psychiatric disorders; the remaining 20 (40%) would not treat mental illness even if they recognised it. Such individuals were presumably referred to specialist facilities for management.

The expert ratings of the knowledge and attitudes of the GPs are summarised in Table 2.

Psychotropic drug stocks

Only 8 (16%) of the GPs stocked a broad range of psychotropic drugs, and only 4 (8%) stocked both antipsychotic and antidepressant medications. Twenty (40%) had only antipsychotic drugs and 10 (20%) had only antidepressant drugs, while 8 (16%) did not stock any psychotropic medications at all.

Discussion

The burden and pattern of psychiatric morbidity can be seen from available epidemiological data (Gureje et al, 1992; Abiodun, 1993). An idea of what is attainable within the primary health system can be seen from research done in other countries (Bilsker et al, 2007; Kates & Mach, 2007; Paria & Perez, 2007).

Nigeria is under-resourced in terms of psychiatric personnel and infrastructure. Access to care for the majority of people with mental illness is severely limited. Efforts to address this problem have so far been targeted at increasing the numbers of psychiatrists and psychiatric nurses, who are often located in urban specialist units.

The PHCs are the facilities closest to the majority of citizens. The research presented here shows that the knowledge base and interest of staff in the PHCs concerning mental illness are low. Further, unlike earlier reports on the matter (Gureje, 2005), it also shows that they do not have even the most basic drugs for treatment.

General practitioners have been a neglected force in mental healthcare planning in Nigeria. If the awareness, knowledge level and attitudes of GPs and PHC workers about mental health could be upgraded in a targeted way, it would lead to an increase in the numbers of people treated for their mental illnesses, especially those with ‘minor’ disorders. It could also create the beginning of a referral chain that would help to prevent the loss to clinical follow-up of individuals who have had specialised treatment in distant teaching hospitals or psychiatric hospital units.