The History, Organization and Future of Psychiatry in Nigeria

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Psychiatry in Nigeria has evolved as the country itself evolved over the centuries.

The history of psychiatry in Nigeria mirrors the history in other countries.

Psychiatric disorders are not the product of modern times but have existed as long as man existed.

From the dawn of history psychiatric disorders have been regarded with awe because the behavioural and emotional presentations were difficult to understand.

The care of the affected has been the province of priest of various gods, and traditional healers of different persuasions including diviner and medicine men.

As to be expected, the methods employed in the management of mental disorders depended on the belief system of the different classes of traditional healers and religious bodies.

There are however the general belief .

That MI can be caused by evil spells and witches
That failure to adhere to the cultural taboo may lead to MI
That gods offended by individual action or failure of action may punish the individual with MI.
That it may be inherited
That natural causes or physical illness may lead to mental illness.
Drugs e.g. marijuana or Indian hemp smoking may cause MI
That environmental factor e.g. adversity may lead to psychiatric problems.

The treatment of mentally ill patients is said to have evolved through three main stages/phases;

Primitive Phase
Humanistic Phase
Scientific Phase

PRIMITIVE PHASE

This appears to have followed the proposal of Heinroth (1773-1843) that mental illness was the product of evil and personal wrong doing.

Accordingly, restraint with chains and corporal punishments were seen as appropriate remedies.

In Nigeria, supernatural power e.g curses, failure to perform sacrifices were taken as aetiology.

Treatment was trying to drive out evil spirits by flogging, stoning and offering sacrifices.

HUMANISTIC PHASE

Hippocrates proposed that mental disorder was as a result of imbalance in body fluids.

He advocated a more humane approach like nutritious feeding and adequate rest.

He also adopted other unacceptable methods of treatment like bleeding and chaining.

Communities started building asylums to keep away mentally disturbed patients.

In 1772, Philippe Pinel was put in charge of one of the asylums.

He started a lot of experiments such as unchaining the patients and giving them some degree of freedom.

This brought about a lot of relief and was an advancement in the management of the mentally ill patients.

SCIENTIFIC PHASE

Erasmus Darwin (1731-1802) introduced physical treatment.

Such as spinning chair which was designed to produce general “shock to the system”.

And perhaps thereby interrupt the morbid preoccupation of the patients.

In 1905, generalized paralysis of the insane (GPI) led to the observation that psychiatric disorders have pathological basis.

In 1934, Manfred Sakel introduced Insulin Coma Therapy for treatment of psychosis. A suitable dose of insulin was used to induce coma which was terminated by feeding or infusion of glucose.

In 1938, Electro-convulsive therapy (ECT) was introduced by Ugo Cerletti and Lucio Bini.

In 1949, the action of Lithium in treating mania was discovered by Cade.

In 1952, neuroleptic drugs came into the picture with the discovery of Chlorpromazine by Daley and Pierre Deniker.

In 1960, community psychiatry (public psychiatry) became prominent. The aim was to treat people with mental disorders in the community and to admit them only briefly and under certain restrictions. This was a departure from the old practice of isolating people with mental disorders for a long period in state hospitals.

Wilhelm Griesinger (1817-1868) was a German neurologist and psychiatrist. He proposed the view that all mental disorders were an expression of single entity (Unitary psychosis).

Benedict Augustin Morel (1809-1873) was an Austrianborn French psychologist.

In 1852, he gave a name Demence precoce to a disorder which he described as starting in adolescence and leading first to withdrawal, odd mannerism, and self-neglect and eventually to intellectual deterioration.

The disorder was later renamed schizophrenia in 1908 by Eugene Bleuler, a Swiss psychologist.

For convenience, the history of psychiatry in Nigeria will be considered under 3 different periods which have been labelled

the pre-colonial era
the transitional era
the modern era

These are not precisely delineated periods but overlap a great deal. As a matter of fact, all the trappings and features of the so-called pre-colonial and transitional era are still much alive today, in the so-called modern era.

In the pre-colonial era, the traditional healers of various descriptions and priests of various religions or gods were responsible for the care of the mentally disordered individual.

In Yoruba land, the traditional healers are classified into

Onisegun – herbalists
Babalawo – Diviners/Priests
Combination of (a) and (b)

All these healers are still very active today, competing with orthodox medical practitioners and psychiatrists in spite of the advance in knowledge and social changes.

Interesting a study conducted in Ibadan revealed that they are patronised by clients that cut across all the social classes.

The practice of the various traditional healers is guided by the various theories of causation prevailing in the practice. The herbalist/Onisegun or

Onisegun (Yoruba) is the precursor or predecessor of the modern physician.

While allowing for natural causes including environmental causes, the possibility of gods playing a role in the causation of the illness is not ruled out.

Management involves the use of medicinal preparation based on plant, animal and mineral resources. Diagnosis involves taking of detailed history and examination of the individual.

The route of administration of the medicinal preparation may be oral, topical and in some cases rubbed into incisions on the skins. Specially prepared soap may be prescribed for washing the head and in some cases the whole body.

The diviner who usually doubles as a priest to some god or gods, on the other hand compares move the spiritual and supernatural causation of the problem.

In consonance with the belief system, the spirit or God/s are consulted to unravel the cause or causes of the illness. The same medium is used to determine the management.

Possession by evil spirit, call for ablution and sacrifices and in some cases flogging.

Atonement for offences against the gods require propitiating and expiratory sacrifices. where the offending spirits are transferred to a sacrificial animal.

The universal believe in the power of words is also brought into play in the management of mental problems. Incantations may be required to force the trespassing spirit to abandon the individual.

The traditional period commenced around the period of annexation of Lagos (became a colony) in 1861 by the British.

At about the same period, the Islamic influence was spreading in the Northern part of the country.

The setting up of the British administration saw to the establishment of courts, Police and prisons for the administration of justice.

Sections of the prisons were designated prison asylum. Mentally ill people were confined to this section.

The basic idea was to keep them away from the public so that they will not be a nuisance.

Similarly, criminal lunatics were also confined there.

Following disagreement between the Public Health department and the Prison department as to who should look after the insane, the first civil lunatic asylum was established in Calabar in 1904, followed by Yaba asylum in 1907.

The asylum was looked after by medical officers, the first of whom was Dr Curtis Adeniyi-Jones. Custodial care was the only method available.

With the advent of the British, the Christian religion spread in the southern part of the country.

Christian sects developed methods of treating mental illness by prayers, induction of trances through a combination of singing, drumming and dance accompanied by repeated prayers and similar utterances by the priest.

In the North, the Moslem healing include offering of prayers, writing verses from the Quran on slates with ink, then washing off the writing with water for the patient to drink.

The first “alienist” posted to Nigeria was Dr Mathew Carmen Blair in 1924. He was stationed in the Northern provinces and from the records; he performed no functions in the area of mental health and was opposed to an official lunacy policy.

From time to time experts i.e. alienist were sent from Britain to attend to the needs in the area of mental health in the country. Dr Home in 1928, Cuyngham Brown in 1934 and Carothers- the first psychiatrist to visit Nigeria in 1956.

Dr D.I Cameron served in Nigeria from 1949 to 1955 and started the plan to build a psychiatric hospital in Abeokuta.

In 1959, Abraham A. Ordia returned to Nigeria as a trained psychiatrist Nurse and took charged of the Yaba asylum and gradually transformed it into a hospital.

The modern era may be said to have begun with his arrival. Dr Cameron (1955) and Campbell Young (1958) worked for a year each in Yaba.

The first two mental asylums were established in Calabar and Yaba/Lagos in 1904 and 1907 respectively.

They were looked after by medical officers, of whom the first was Dr. Crispin Curtis Adeniyi-Jone (at Yaba asylum).

In 1936, Dr. R Cunyngham Brown also wrote a report on how best they can be taken care of. Part of his suggestions was that a mental hospital should be built near Abeokuta.

The Second World War prevented the implementation of his recommendation for about a decade.

Lantoro asylum was established in 1944.

In 1948, Dr Cameron Blair became the first alienist to work in Lantoro asylum.

Dr Walker and subsequently, Sir Samuel Manuwa who took over as the medical director for the country then persuaded Prof. Thomas Adeoye Lambo to go and train abroad.

In 1954, Nigeria had a first fully qualified psychiatrist but when he came back, Aro site was not yet completed.

The arrival of Prof. Thomas Adeoye Lambo in Nigeria in November 1954 coincided with what is described as the commencement of modern psychiatry in Nigeria. ⚫ This led to the establishment of Aro village system.

This made Prof Thomas Adeoye Lambo become very popular.

The first Nigerian trained as a psychiatric nurse was Mr. A.A Ordia.

He was in charge of Yaba asylum from 1951 until 1961 when two psychiatrists took over.

Psychiatric Nursing Training started in Nigeria in 1956.

The first Nigerian Psychiatrist started work in Abeokuta in 1954, first in Lantoro but later moved to Aro which was still under construction then.

He soon started the famous Aro Village. He believed that patients would do better when treated in an environment similar to their normal environment.

The programme was a success and enjoyed worldwide renown. Dr Asuni joined Aro in 1957 and he also established another village, Idi-ori, based on the same principle.

ARO VILLAGE SYSTEM

Aro Hospital proper (an open unit)

Lantoro annex (a closed unit)

Patients were allowed to lodge in surrounding villages in exchange for water and electricity which were lacking in those villages and government then provided.

They sleep in the village and go to the hospital in the morning then go back to the village in the afternoon for lunch and for recreational activities in the evening.

It was found that the patients that had this freedom did better because the environment where they were being taken care of was not much different from the one they came from.

In 1961, the number of psychiatrists increased to 4.

By 1972, their number increased to 17, with 15 being Nigerians.

They also reported on the available facilities as 11 mental hospitals, 12 psychiatric units in university teaching hospitals, 8 psychiatric units in state general hospitals, 5 units in Armed forces hospitals, 1 community mental health out-post of a state hospital and 7 private hospitals specializing in the care of the mentally ill patients.

The first female psychiatric nurse Miss Irene Ogbolu took charge of the Calabar asylum and restructured it into a hospital. She was later joined by another psychiatric nurse Mr Balogun from Yaba. Together they were responsible for psychiatric care in the Eastern part of the country.

In the North Dr H.S Paul; a Briton served as a psychiatrist in Jos and Zaria from 1958 to 1960. Dr C.O Oshodi the first Nigerian Psychiatrist to work in the North arrived in 1961 and transformed the asylum into a psychiatric hospital.

The first Pan African Psychiatric conference was held in Aro in 1961 and this attracted worldwide attention. In 1963 Professor Lambo assumed the first chair of psychiatry in Nigeria at the University of Ibadan in 1963, and was succeeded in Aro by Dr T Asuni, assisted by Drs Otolorin and Oluwole and others from abroad: Dr R.H Prince from Canada, Dr V.M Severas from Austria; Dr S.M Collins from Ireland; Dr X. Fernandes from India and Dr Schoenbery from Germany at various times. Unfortunately, Dr X Fernandes died in active service.

The creation of the mid-west region led to the establishment of the Psychiatric hospital there. Mr J.O Obaseki (1964) a psychiatric nurse started the clinic in Benin and this was developed by Dr Binitie (1968) who following the Aro village concept established the “Therapeutic Neighbourhood”.

On the academic side, Dr A. Anumunye became the first professor of psychiatry at the Lagos University Teaching hospital, while Binitie and J.O Ebie assumed chairs of psychiatric-Benin. Dr C.O Oshodi established the first psychiatric department at the Ahmadu Bello University Kaduna; he later moved to establish psychiatric services in Kabba.

The first psychiatric school of nursing started at Aro in 1957. The trainees after spending some time at Aro proceeded to UK to complete their training. The school was housed in a temporary, wooden building and remained until a modern school was built on the same site in 1997.

Great strides have been made in psychiatric care and virtually all Universities in the country now have psychiatric departments while there is no state without psychiatric service.

With the introduction of local training in psychiatry, the establishment of National Postgraduate Medical College and West African Postgraduate Medical College, the number of psychiatrists have expanded exponentially.

Virtually all the Universities (there are over 50) have departments of psychology producing valuable manpower for the sector.

The current situation is that the traditional healers, religious sects, and psychiatrists are still very active in the area of mental health care, thus the pre-colonial, transitional, and modern eras of psychiatry are still with us.

Nigeria's mental health legislation was first enacted in 1916 and was called the Lunacy Ordinance. In 1958, these laws were amended to give medical practitioners and magistrates the power to detain an individual suffering from mental illness.

Renamed the Lunacy Act of 1958, these laws had not been amended until recently.

This legislation was outdated and archaic, reflective of a period in human history not only when mental health was severely misunderstood but also when the treatment of people with mental health-care needs was both inhumane and ineffective.

In 2003, a Mental Health Bill was put forward to the National Assembly of Nigeria.

With little support and no progress for more than 6 years, it was withdrawn in April 2009. This Bill was presented again in 2013 when the National Policy for Mental Health Services Delivery set out the principles for the delivery of care to people with mental, neurological, and substance abuse problems.

Again, facing scant support, it did not become law.

In the absence of a dedicated authority to assess compliance or support legislation, the effect of this policy on the quality of care and life for people living with mental health problems in Nigeria remains negligible.

Nigeria currently faces a global human rights emergency in mental health.

Underpinned by poor societal attitudes towards mental illness and inadequate resources, facilities, and mental health staff, figures suggest that approximately 80% of individuals with serious mental health needs in Nigeria cannot access care.

With fewer than 300 psychiatrists for a population of more than 200 million, most of whom are based in urban areas, and in view of poor knowledge of mental disorders at the primary health-care level, caring for people with mental illness is typically left to family members.

A paucity of community-based and primary healthcare services means that access to care is restricted to the most severe cases, usually in the form of psychiatric inpatient care or makeshift institutions. The result is a chronically and dangerously underresourced mental health system catering to the needs of an estimated one in eight Nigerian people who suffer from mental illness, poor awareness of the causes of mental health, widespread stigma and discrimination, poorly equipped services, and abuse of people with mental health problems.

A reform of the mental health law that is in keeping with international standards is urgently needed to drive change.

The global target of WHO's mental health action plan aims for 50% of countries to have developed or updated their law in line with international and regional human rights instruments by 2020. In 2017, only 40% of WHO member states had updated their legislation in the previous 5 years (i.e., since 2013).

Africa had the lowest rate at 21%, although this rate had doubled since 2014. On Feb 19, 2020, the Nigerian Senate held a public hearing for the Mental Health and Substance Abuse Bill.

The Bill would allow for much needed budgetary allocations for mental health facilities and mental health providers.

The time is now for mental health legislation and policy in Nigeria to protect individuals suffering from mental illness from being subjected to gross human rights violations, including degrading treatment and destitute living conditions.

Widespread consultation with key stakeholders, including the Association of Psychiatrists of Nigeria and community representatives, was done.

In strong support of this Bill, we further put forward several considerations.

Specifically, it is necessary for any resulting legislation to be in accordance with the WHO Checklist on Mental Health Legislation to ensure that it meets international standards.

Second, legislation should be culturally sensitive and meet the human rights standards as set out by the International Covenant on Economic, Social and Cultural Rights and the African Charter on Human and Peoples' Rights.

Third, there is a need for mental health services to be a covered mandate in the national health insurance scheme to ensure accessibility and affordability of care.

Fourth, and in line with best practice, additional support for outpatient, primary, and community care services for people with mental illness is advocated.

Finally, and in view of the severe dearth of human resources for mental health, we call for the integration of mental health training, responses, and psychoeducation within primary care settings, as contained in the National Mental Health Service Delivery Policy of Nigeria.

Legislation that works for all is important to help improve the health of the nation and to safeguard the care of all Nigerian people, today and for the future.

The Nigerian Mental Health Act of 2021 was passed into law on January 5th, 2023.

The Lunacy Ordinance was enacted in 1916, which preceded the Lunacy Act of 1958, Nigeria’s first mental health legislation.

This is after over 6 decades of trying to appeal the outdated colonial mental health legislation of 1958.

This new law protects the rights of the mentally ill.

It helps to promote and protect the lives of people suffering from mental illness while also addressing and correcting the flaws in the Lunacy Act.

It also emphasizes the government’s role in closing Nigeria’s massive mental health gap and eventually achieving Universal Health Coverage.

The Objectives of the Mental Health Act

To provide direction for a coherent, rational, and unified response to the delivery of mental health services in Nigeria.
Promote and protect the fundamental human rights and freedom of all persons with mental health conditions and ensure that their rights are guaranteed.
Ensure a better quality of life through access to integrated, well-planned, effectively organized, and efficiently delivered mental healthcare services in Nigeria.
Promote the implementation of approved national minimum standards for mental health services in Nigeria.
Promote recovery from mental health conditions and enhance rehabilitation and integration of persons with mental health conditions in the community.
Facilitate the adoption of a community-based approach to the provision of mental health care services.
Facilitate the coordination of mental health service delivery in Nigeria.