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The Nigerian Mental Healthcare System and Mental Illness: A Systematic Review

Fashoto Olubunmi Yemisi*1, Ayangeaor, Joseph Iniongun2,Akinkunmi Francis3and Shongwe Nompumelelo4

1Department of Psychology, Eswatini Medical Christian University, Hhohho, Mbabane, Eswatini.
2 Department of Psychology, Faculty of The Social Sciences, University of Ibadan, Nigeria.
3Assistant Director of Psychological Services, Department of Psychology, Federal Neuropsychiatric Hospital, Yaba, Lagos, Nigeria
4Mental Health Specialist, World Vision, Mbabane, Eswatini.

*Corresponding author

*Fashoto Olubunmi Yemisi, Department of Psychology, Eswatini Medical Christian University, Hhohho, Mbabane, Eswatini

Abstract

Introduction: One out of four people are affected with mental disorder globally at a particular point in their lives and the mental health incidences during the present pandemic indicate the unpreparedness of the continent. Mental illness needs timely detection and prompt intervention which can aid in slowing down illness.
Purpose: This study carried out a systematic review of recent studies on mental healthcare in Nigeria, while also taking into account the challenges of Nigeria’s mental healthcare system and recommendations that have been made.
Methods: The PRISMA guidelines informed the screening and inclusion of studies from 4 electronic databases (African Journals Online (AJOL); Global Health; PsycINFO; and PubMed). The initial search generated a total of 701 eligible studies which were further screened to the 27 studies that sufficiently met the inclusion criteria. Only empirical studies published in English language between January 2020 and June 2024 were included in the review.
Results: The study identified high prevalence of mental illness in Nigeria which can be significantly linked to socioeconomic factors and insecurity. These factors create a challenging environment that may be contributing to the mental health crisis in the country.
Conclusion: There is an urgent need for a reformation of the mental healthcare system in Nigeria.

Keywords: Mental illness, Mental Healthcare System, Reformation, Nigeria

Introduction

Nigeria is currently confronting a mental healthcare state of emergency, as an overwhelming number of individuals with mental healthcare needs could not access the needed care (Ugochukwu et al. 2020). The prevalence of mental illness in Nigeria is exacerbated by economic hardship, high unemployment, violence and insecurity, migration and displacement, healthcare system challenges, poor living conditions, and a high rate of substance abuse among other factors. A recent mental health survey in Nigeria revealed that the prevalence of mental illness is estimated at approximately 20% of the population of over 200 million people, that is, about 40 million people in Nigeria suffer from mild to severe mental illness (Africa Polling Institute and EpiAFRIC, 2020).  In Nigeria, mental health awareness is generally low, some attributed mental illnesses to the possession of evil spirits, drug abuse, and mostly embraced prayer camps for spiritual interventions (Ozota, et al, 2024; Africa Polling Institute and EpiAFRIC, 2020).  Poor living conditions, limited access to mental health services, and low educational attainment were also identified to increase incidences of mental illness (Fadele et al. 2024). Help-seeking behaviors among Nigerian families from low and middle socioeconomic backgrounds is impeded by financial constraints and social stigma, which deterred them from accessing necessary mental health services (Ogueji & Okoloba 2022).

Shortage of mental healthcare professionals in public neuropsychiatric and mental health facilities servicing over 200 million people has further exacerbated the mental health burden among the population (Eaton, et al, 2017; Wakida, et al, 2018; Okafor, et al, 2022; Ogbonna, et al, 2020). Statistics show that about 80% of people with severe mental healthcare needs in Nigeria are unable to access professional care due to a lack of sufficient mental health facilities, resources and mental health professionals (Fadele, et al., 2024). Ideally, about 71% of the population is expected to access a primary healthcare facility located within a 5-kilometre distance within the community (FMoH, 2007). Sadly, many of these primary healthcare centres are hardly found within this distance, while those that are found have no qualified mental healthcare professionals, and lack the necessary equipment and essential supplies thus, do not provide mental healthcare services (Anyebe et al., 2020).

Nigeria currently encounters several challenges in the provision of mental healthcare services as well as the operationalization of a viable mental healthcare system. It has been noted that the obstacles confronting the design and implementation of an effective mental healthcare system in Nigeria relate to policy formation and implementation, consistent poor budgetary allocations to the healthcare sector, inadequate mental health education initiatives and the integration of mental healthcare services in the primary healthcare systems (Ozota, et al, 2024; Okafor, et al, 2022; Bamgboye, et al, 2021). Analysis of the socioeconomic consequences of mental distress found a strong correlation between mental health issues and economic instability, perpetuated by the cycle of poverty and indicated the need for comprehensive socioeconomic policies (Bamgboye, et al (2021; Okafor, et al, 2022; Ogbonna, et al, 2020). Therefore, this study seeks to undertake a systematic review of recent studies to evaluate the status of mental healthcare provision in Nigeria with the purpose of assessing and synthesizing empirical evidence that explains the current situation and provides information that can inform a strategic intervention. To this end, the review provides answers to two (2) specific research questions:

  1. What is the current status of mental health and the Nigerian mental healthcare system? and
  2. What are the major challenges faced in the provision of mental healthcare services in Nigeria?

Methods & Results

The study adopted a systematic review design that was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (Page, et al, 2021), to review research publications in the literature on the mental healthcare system and service provision in Nigeria. The focus is to synthesize findings from various studies on the subject and provide an understanding of the current status, challenges, and recommendations for improving mental health services in the country. Four (4) electronic databases: PubMed, PsycINFO, African Journals Online (AJOL), and Global Health, were explored using an iterative search process. Only peer-reviewed articles, reports, and theses focusing on mental illness in Nigeria and the mental healthcare system, published in the English language between January 2020 and June 2024, were selected and screened for the review. Relevant studies identified in the references of the selected articles, which met the inclusion criteria were also searched and included in this review. Conversely, articles on the subject but not focused on Nigeria, non-peer-reviewed articles, opinion pieces, and articles not providing empirical data or systematic reviews were excluded from this study. The keywords used as search terms include:  "Mental illness/disease/disorder prevalence in Nigeria", "Mental healthcare system in Nigeria", "Challenges of mental healthcare in Nigeria", and "Mental health service provision Nigeria". The selection process involved an initial screening of titles and abstracts that were reviewed to exclude irrelevant studies, while a full-text review involved selected articles that met the inclusion criteria. Data was extracted using a standardized form, capturing information about the study design, population, key findings, and recommendations. Quality assessment of reviewed studies was achieved with the application of critical appraisal tools for different study designs by the Joanna Briggs Institute (Aromataris, et al, 2015), using criteria for the quality of methodology, relevance, and clarity of results. The data synthesis approach employed a thematic analysis method to synthesize qualitative data and narrative synthesis for quantitative data. The results are presented in tabular narrative forms, highlighting the author(s), title, year, method and conclusion of the selected studies.

Results
The screening process involving 701 selected journal publications on mental healthcare in Nigeria, produced 27 research articles that fulfilled the eligibility criteria and were included in this analysis. The PRISMA screening guide flow chart demonstrating these articles' selection process is presented in Figure 1. These articles provided empirical information on issues relating to the current status of the mental health and healthcare system in Nigeria; the major challenges faced in the provision of mental health services in Nigeria, and various recommendations that have been proposed to improve mental healthcare services in Nigeria. Table 1 presents a summary of the screening of the 27 articles that were reviewed in this study.

Figure 1: Flow chart of the Study Selection Process.

Information in Figure 1 shows that the initial search generated a total of 701 articles from 4 databases (AJOL, Global Health, PsycINFO, and PubMed), which were further screened down (based on the inclusion/exclusion criteria) to the 27 publications included in this analysis.

Table 1: Summary of Studies Included in the Review.

Table 2 presents the characteristics of studies included in this review, which shows that all studies were carried out in Nigeria and published between January 2020 and June 2024. Majority of studies included in this review utilized a cross-sectional survey method 12 (44.5%), while other studies adopted a descriptive survey method 6 (22.3%), systematic review 5 (18.5%), qualitative method 2 (7.4%), mixed-method 1 (3.7%), and case study 1 (3.7%) respectively. A total sample size of 26,430 participants provided various primary data across selected studies under review.
Table 2: Characteristics of Studies Included in the review (n = 27).

Prevalence of mental illness
Table 3 presents studies with different topics that examine the prevalence of mental illness in Nigeria. It showed a summary of recent studies with various topics that investigated and reported different types of mental illnesses. These studies specifically provide empirical evidence on the prevalence of mental illness across the Nigerian populations. Studies presented in both Tables 3 and 4 explain the current status of mental health and service provision in Nigeria.

Table 3: Recent Studies That Reported Prevalence of Mental Illness in Nigeria.

In contrast, Table 4 presents a highlight of studies that investigated mental healthcare service provision in Nigeria. Highlights of the studies focused on mental healthcare service provision in Nigeria.

 Table 4: Recent Studies on Mental Healthcare Service Provision in Nigeria.

Challenges in Providing Mental Healthcare
Research question 2 sought to review empirical studies that examined challenges associated with the provision of mental healthcare services in Nigeria. Evidence from the literature that challenges involved in the provision of mental healthcare services revolve around policy, infrastructure and professional training. Table 5 highlights studies that investigated the Nigerian healthcare system and mental health service provision. It provides a summary of studies that assessed the major challenges hindering a transformation of the Nigerian mental healthcare system.

Table 5: Highlight of Recent Studies on Nigeria’s Healthcare System.

Discussion

Most studies that investigated the current status of mental health in Nigeria identified depressive disorders (Ogungbemi et al, 2024; Osahon et al, 2024; and Nweke et al, 2024), anxiety disorders (Chinawa et al, 2023; Izuka et al. 2023; and Falade et al, 2020), substance abuse-related (e.g., alcohol, cannabis, stimulants, and opioids) disorders (Oguntayo et al, 2022), and schizophrenia (Balarabe et al, 2022) as major mental illnesses across populations. The high prevalence of mental illness in Nigeria can be significantly linked to socioeconomic factors and insecurity. These factors create a challenging environment that may be contributing to the mental health crisis in the country. For example, Nigeria has a high poverty rate, with a significant portion of the population living below the poverty line. Unfortunately, financial stress and the struggle to meet basic needs such as food, shelter, and healthcare has been found to associate with chronic stress, anxiety and depression (Ogungbemi et al, 2024; Falade et al, 2020). Nevertheless, the high unemployment rates in Nigeria, particularly among the youth, contribute to feelings of hopelessness and frustration, and the lack of job opportunities and economic instability can exacerbate mental health issues (Fadele, et al, 2024; Ogueji and Okoloba, 2022; Bamgboye et al, 2021). Conversely, the ongoing conflicts and terrorist activities, particularly in the northeastern region of Nigeria, such as the Boko Haram insurgency and banditry have led to widespread displacement, trauma and loss. These experiences can result in post-traumatic stress disorder (PTSD), anxiety and depression among the affected populations (Bamgboye et al, 2021). High rates of violence and crime, including armed robberies, kidnappings, and communal conflicts, create a pervasive sense of insecurity. The constant fear for personal safety and the safety of loved ones can lead to chronic stress and mental health disorders. Moreover, internal displacement due to conflicts and natural disasters leaves many people without stable homes and livelihoods. Living in temporary camps or inadequate housing conditions can exacerbate mental health issues due to instability and lack of support systems. In regions affected by high levels of insecurity and poverty, substance abuse can become a coping mechanism, which can lead to a cycle of addiction and further mental health deterioration.

The prevalence of mental illness in Nigeria is exacerbated by inadequate access to mental health services. The Nigerian healthcare system is often under-resourced, with a scarcity of mental health professionals and facilities (Okafor et al, 2022; Ogbonna et al, 2020; Ugochukwu et al, 2020). This situation makes it difficult for individuals to receive proper diagnosis and treatment thus, contributing to the high prevalence of mental illness in the country. Mental health services are concentrated in urban areas, making it difficult for people in rural areas to access care. In some cases, the transportation costs and distances are significant geographical barriers. The cost of mental healthcare can be prohibitive for many Nigerians, especially given the high levels of poverty and limited insurance coverage for mental health services. Challenges to the accessibility, quality and effectiveness of mental health care for the population have been lamented by various stakeholders. Ozota et al. (2024) noted that mental health care is significantly underfunded compared to other health sectors, and this is the resultant effect of insufficient facilities, medications, and resources necessary for effective treatment. Many of the existing mental health facilities are outdated and lack basic amenities, while the few existing psychiatric hospitals are often overcrowded and in poor condition (Okafor et al, 2022). The challenge of the infrastructural deficit is compounded by a fast-depleting professional workforce. There is a severe shortage of psychiatrists, psychologists, psychiatric nurses, and social workers as Nigeria has one of the lowest ratios of mental health professionals to the population in the world (Sodeinde et al, 2024; Mba-Oduwusi et al, 2024; Association of Psychiatrists of Nigeria, 2018). Many trained professionals emigrate in search of better opportunities, further depleting the already limited workforce.

Although the passage of the National Mental Health Act No. 46 of 2021 into law may seem to have addressed policy and legislation issues, there exists a lack of effective implementation and enforcement. The general psyche of the population about mental health law in Nigeria is the provisions of the Act of 1958, which does not adequately address modern mental health needs. Conversely, mental health services are not well integrated into the general healthcare system and are completely lacking at the primary healthcare level (Ezuruigbo, 2022; Chu et al. (2022). Research findings show that only a fraction less than 10% of the over 40 million mentally ill persons in Nigeria have access to appropriate mental healthcare services (Okafor, et al, 2022; Ogbonna, et al, 2020). Despite available scientific reports, research on mental healthcare issues specific to Nigeria remains insufficient, leading to a gap in understanding and addressing the unique challenges faced by the population. Inadequate data collection and monitoring systems make it difficult to track mental health trends and the effectiveness of interventions. For instance, mental illness is highly stigmatized in many parts of Nigeria. People with mental health issues are often discriminated against, leading to social isolation and reluctance to seek help. Also, the lack of awareness and education about mental health contributes to misinformation, myths and misconceptions, which reinforces negative attitudes. Many general healthcare providers lack adequate training in recognizing mental health issues, leading to underdiagnosis and mistreatment.

Strengths and Limitations
Based on the methodology, the strength of this study lies in its systematic identification, evaluation, and synthesis of up-to-date empirical evidence on mental health and the mental healthcare system in Nigeria. Therefore, the study provides information and a recommendation that is informed by the current status of the mental healthcare system in Nigeria. Also, this review adopts a well-defined, transparent, and comprehensive search strategy, which increases the reliability and validity of the review findings. Lastly, its clearly defined inclusion and exclusion criteria were essential and ensured that only the most recent (2020 - 2024) high-quality, relevant studies were included, which enhanced the review's overall quality. Each study included in the review was assessed for quality using standardized tools and criteria and this step helped to identify and mitigate the impact of biases in individual studies.

There were some limitations to this systematic review. Firstly, the studies included in this review did not sufficiently cover all the geopolitical regions in Nigeria that share various cultural beliefs and approaches to mental health. The findings, therefore, may suffer from the principle of generalization. Secondly, most of the studies included in this review utilized a cross-sectional survey research design that was single-centered. Cross-sectional surveys are not ideal and capable of making a cause-and-effect relationship between s study variables. Thirdly, many of the studies that examined the prevalence of mental illness in Nigeria; included in this review, hardly mentioned the diagnostic criteria used. It is unclear whether the cases reported were based on the outcome of DSM-5 or ICD-11 diagnostic criteria thus, many cases reported may have been a case of misdiagnosis. Lastly, though some of the studies included in this review utilized effective methodologies in gathering and analyzing data on the state of mental healthcare facilities and service provision, however, most of these studies failed to explain the role of digital technologies in bridging the service provision gap, as a growing practice among the professionals.

Conclusion

Despite the limitations in this review, it is safe to conclude that there is a likelihood of a surge in mental illness in Nigeria as the country currently undergoes a difficult socioeconomic transformation amidst challenges of insecurity, which findings have shown to associate with chronic stress, trauma, anxiety and depression.  The implication, therefore, is that there is an urgent need for a reformation of Nigeria’s mental healthcare system to integrate mental healthcare services at the primary healthcare centres, build and equip more facilities and road network, and provide competitive remuneration and work conditions that will mitigate the current brain drain syndrome and mass exodus of mental health professionals.

Conversely, an emerging issue in the provision of mental healthcare services in developing countries such as Nigeria, is the utilization of digital technologies for the provision of therapeutic and other mental healthcare interventions. Therefore, it is instructive for future studies that will be carried out by anyone desirous of investigating mental illness and service provision in Nigeria to also include the role and effect of digital technologies in the provision of mental healthcare services, which has not been sufficiently explored in the current review.

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