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Yale Contingent Confronts Mental Illness Stigma in Nigeria

01/04/2012: Recent surveys indicate that nine of ten persons with mental disorders in Nigeria do not receive services. Despite a population of roughly 150 million, the country has few trained psychiatrists—roughly one psychiatrist for every million residents.

In November 2011, Robert Rosenheck, MD, professor of psychiatry and of public health, and addiction psychiatry fellows Theddeus Iheanacho, MD and Carla Marienfeld, MD visited Nigeria to get a firsthand look at the challenges facing mental health care in this West African nation.

Nigerian-born Dr. Iheanacho, who completed an internship year in Nigeria and is licensed to practice medicine there, made the initial connection. The trip was made possible by funding from Yale-New Haven Hospital Medical Staff in support of international elective experiences for residents.

During the visit, the Yale team conducted basic psychiatric training for approximately 80 medical and nursing students at an academic medical center in the city of Owerri.

"There was a recognition among the school's administrators that psychiatry is an integral part of medical education, but they had no capacity to provide it," said Dr. Rosenheck describing the trip's fortuitous timing. "We were lucky to be able to fill a very essential gap."

"Several of the students said our trainings were their first exposure to psychiatry," added Dr. Marienfeld. She noted that a number of the students eagerly participated in the interactive discussions. "We deliberately took a non-didactic approach including some role-playing. They seemed to particularly appreciate the use of Socratic methods."

Engaging and listening to the students was a critical component of the experience. "We were there as much to learn as to teach. Applying our idea of what's best for the treatment of a mental disorder may not make sense given a whole range of factors including the natural history of the disease in that setting," said Dr. Iheanacho. "Not to mention many of our most common medications are simply unavailable there."

A survey of Nigerian households identified the stigma associated with mental health and addiction as one of the biggest obstacles to care. Drs. Rosenheck, Iheanacho and Marienfeld administered the same survey among the residents and students they met with to compare this new data with the population at large. Follow-up surveys will determine if the exposure to medical models and formal psychiatric training will change perceptions among the students over time.

The stigma, says Dr. Rosenheck, stems largely from the region's culture and traditions. "If a family member exhibits symptoms that western medical professionals might associate with mental illness, available research suggests that Nigerians might think that person has been bewitched or cursed." Someone seeking help for a mental illness will likely turn to their church or a traditional healer before a medical doctor.

Following the visit, school administrators in Owerri are considering expediting plans to hire a psychiatrist, develop a full psychiatric consultation service, and convert a nearby abandoned medical facility into an affiliated psychiatric hospital. Rosenheck, Iheanacho and Marienfeld remain engaged with their contacts and Dr. Iheanacho has offered clinical consultations on an as-needed basis.

In addition, the team met with medical residents at Nigeria's oldest medical school, located in Ibadan, as well as Nigerian Drug Law Enforcement Agency (NDLEA) officers.

Marienfeld, who spearheaded development of the department's Global Mental Health Program as a resident, summed up the reason these visits are so important for U.S. trainees and faculty, "You can read all the available global mental health statistics, research, and theory, but unless you have a direct experience in an underserved country like this, you will never fully grasp the need, the challenges, and the resource deficits, or know which efforts can have the most impact."

For more information:

Global Mental Health Program

Drs. Rosenheck, Iheanacho and Marienfeld with psychiatry residents, attendings and the chairman of the psychiatry department, University of Ibadan Teaching Hospital.
(left to right) Carla Marienfeld, MD and Theddeus Iheanacho, MD, addiction psychiatry fellows with Robert Rosenheck, MD, professor of psychiatry and of public health.