In remote Imo State, one of 36 states in the African country of Nigeria, it is virtually impossible to get a mental health care referral.
“There is so much need,” said Theddeus Iheanacho, M.D., associate professor of psychiatry at Yale School of Medicine.
Iheanacho and his HAPPINESS Project colleague Charles Dike, M.D., also an associate professor of psychiatry at the medical school, both hail from Imo State. The two understand how badly underserved the population is, especially in the rural areas. There are no psychiatric hospitals across the 2,135-square-mile territory, and the state counts only one full-time psychiatrist to serve its nearly 5 million residents.
“You can imagine if Connecticut had one psychiatrist and no psychiatric hospital,” said Iheanacho, who in 2018 launched, with support from Dike, a program to train primary care workers in Imo State to screen for, assess, and treat mental health conditions like depression, psychosis, and anxiety. “Most of these people would otherwise not have access to treatment or else would have traveled five or six hours to get it. Anything we can do to push the needle, even if we can only get 100 people into care, it’s worth it.”
Called the HAPPINESS Project — Health Action for Psychiatric Problems in Nigeria including Epilepsy and Substances — the program initially taught more than three dozen healthcare workers how to integrate mental health services into routine primary care. Over 50 patients were seen after the first training session, and many more people who otherwise would have gone without treatment are now being evaluated and treated by clinicians.
Expanding the project
This partnership between Yale School of Medicine’s Department of Psychiatry and Imo State University Teaching Hospital is supported by the Yale Global Mental Health Program, CBM International, the Imo State Primary Health Care Development Agency, Row Foundation (USA) and the Imo State Government. The goal is to expand the program to all primary care facilities in Imo State, and eventually to other Nigerian states. On Jan. 17, during a four-day trip to Nigeria that is part of the Yale Africa Initiative, Yale President Peter Salovey will meet with officials to finalize plans for expanding the project.
Iheanacho described how his interest in psychiatry as a profession blossomed when he encountered the advanced mental health system and care in Dublin, Ireland and England. “When I went there for my postgraduate studies, I saw how effective treatments can be, and that people with psychiatric disorders can recover and live full lives,” he said.
Dike also traces his initial interest in improving mental health care in Nigeria to his study abroad.
“Growing up and attending medical school in Nigeria, psychiatry was not considered an important or desirable career choice,” he said. “It wasn’t until my exposure to it in England that I fell in love with it.”
Dike’s change of focus came as a pleasant surprise to him.
“I had not believed any medical specialty would supplant my natural — and rigid — inclination toward the surgical specialties.”
Once he determined he would pursue psychiatry, he said, his next task was convincing his parents and family back home in Nigeria that this was the right choice for him — “a herculean task indeed, given the deep and enduring stigma around mental illness. I am delighted to participate in a program that will start the gradual process of change; if I could change, anyone can.”
Doctors at work
With the successful launch of the HAPPINESS Project well underway, Iheanacho and Dike recently visited Owerri, the capital of Imo State, accompanied by Nichole Roxas, M.D., M.P.H., a second-year resident in the Yale Department of Psychiatry. Using project manuals and training protocols based on the World Health Organization’s mental health Gap Action Programme (mhGAP), they conducted refresher training for the primary care teams that, before their introduction to the HAPPINESS Project, had limited or no experience providing mental health services.
Among the topics discussed at the September 2019 meetings in Owerri were diagnosis and treatment options for patients; patient follow up; clinical supervision; child and adolescent mental health; referrals for substance use disorders and rehabilitation; use of language to reduce stigma in mental health; and psychoeducation, psychosocial support, and counseling for patients and their families.
Dike said the trainees are passionate about the program and have sought out opportunities to be educated, whether through group training sessions like the one in September or via the web through a telemedicine service. Case conference and continuing education calls are being conducted once a month between Yale and Nigeria via a web messenger, and a special training app is in development.
“Whatever you do, as small as it is, a drop in the bucket goes a long way for people who are so eager to be served,” Dike said.
Iheanacho and Dike said the program has been embraced by some Nigerian government agencies, but that the trainees have sought ways to expand the base of support in their villages. “We realized there is a need to include some community resources — for example, some connections to the churches and community leaders,” Iheanacho said. “The churches can give us referrals, and the community leaders can publicize (the program). We’re continuing to think about the best ways to engage people.”
Continued marketing of the program throughout Imo State should generate even more patient interest in the service, Iheanacho said. There was discussion at the September meeting about creating project “advocacy kits” with posters, flyers, branded jackets, or T-shirts. Participants also suggested creating HAPPINESS Project Facebook and web pages.
‘We are committed’
The physical distance between Connecticut and Imo State presents an obvious challenge, but one that for the most part has been eliminated by technology.
“It’s a lot of work, but we are committed,” said Iheanacho.
In addition to providing a critical resource to the people of Imo State, the HAPPINESS Project has inspired people like Roxas, the medical resident, who jumped at the opportunity to travel to Nigeria and witness it in person.
“I really wanted to be a part of this because I felt like it was a rare example of what sustained global mental health can look like,” she said. “People are really passionate about this on the ground, the people who are trained. Some people volunteer to go out on their own to educate community leaders about it.”
It’s that excitement and shared desire to reach more needy people that inspires Iheanacho and Dike to push the program forward.
“It gives us hope and encouragement to press even further, to go deeper into the areas we have already started, and to expand to areas where we have not yet gone,” Dike said. “It just pulls at our heart strings to go (to Imo State) and participate in change.”