With about 200 psychiatrists for an estimated population of 198 million people, Nigeria exemplifies the severe lack of capacity for mental healthcare services in low and middle-income countries (LMICs). An estimated 26% of adult Nigerians have a lifetime prevalence of at least one Diagnostic and Statistical Manual (DSM IV)-coded mental disorder, a rate similar to that in high income countries, yet only 10% receive any care irrespective of severity. A significant factor limiting access to mental health care in Nigeria is limited availability of mental health specialists. Other factors are pervasive societal negative attitudes and stigmatizing beliefs about mental disorders even among health care providers. Finding innovative approaches to reduce barriers and increase access to effective treatments for these common mental disorders in LMICs like Nigeria is in line with WHO Millennium Development Goals and the 2030 Agenda for Sustainable Development and its Goals. The challenge is to find efficient, effective, acceptable and sustainable ways to do this. An increasingly accepted and effective approach is training lay and non-psychiatric health workers to deliver packages of mental health care under the supervision of psychiatrists in a collaborative, stepped-care, task sharing approach.
Although the WHO’s mhGAP intervention guide (mhGAP-IG) supports this approach and has been recently contextualized and piloted in Nigeria, key research questions remain unanswered.
- Feasibility: Can the mhGAP-IG be implemented routinely in primary care centers? What is the role of mobile technology in increasing the reach of the few distantly located psychiatrists to provide supervision and clinical support for primary healthcare workers?
- Acceptability: Will primary healthcare workers and service users accept mental health screening, treatment and referral in the community health centers?
- Effectiveness: What is the impact of mhGAP-IG implemented in primary health centers on clinical and functional outcomes compared to usual care? Can a project like the HAPPINESS Project reduce the gap in access to mental health care compared to usual care? Can it reduce stigma and negative attitude among health care workers and the general public?
- Sustainability and scalability:If effective, can The HAPPINESS project be supported by existing state health infrastructure, personnel and policy framework? Is it scalable to all primary care centers in Imo state and other states in Nigeria?
- What are the mediators, facilitators or mitigating factors for feasibility, acceptability, effectiveness, sustainability and scalability of an mhGAP-based project like The HAPPINESS project?
These and other research questions can only be answered with a well-designed, rigorously implemented pilot and clinical trial study. With further funding and support, our team is well positioned and prepared to answer these implementation research questions.