Reducing depression-related deaths in Nigeria

Today, April 7, is World Health Day (WHD). The theme of 2017 campaign is depression. CHUKWUMA MUANYA, Assistant Editor, in this report examines factors predisposing more Nigerians to depression, the consequences and what could be done to address the menace.

Thirty five year-old Emmanuel Orji is living with sickle cell anaemia. Dr. Emma, as he was fondly called, worked at a hospital in Lagos as trainee doctor. Emma found it hard dealing with the crisis associated with the disease. He was depressed. Emma took his life last month by jumping into the Lagos Lagoon.

Major 56-year-old Mfon Uduak was a brilliant soldier. He had two of his children schooling in prestigious institutions in the United Kingdom (UK). Mfon was one of the estimated three million Nigerians who participated in the Mavrodi Mondial Moneybox (MMM) scheme. He lost N20 million as the scheme froze accounts and made it impossible for members to withdraw their money. Not able to withstand the disappointment, Mfon shot and killed himself.

Emma and Mfon represent about 7,079,815 Nigerians that are depressed and are more likely to commit suicide.

Consultant Psychiatrist and coordinator of Lagos University Teaching Hospital (LUTH) Suicide Research and Prevention Initiative (SURPIN) project, Dr. Raphael E. Ogbolu, told The Guardian yesterday that about 3.9 per cent of Nigerians have depression.

The psychiatrist said this level is significant because it means that about seven million Nigerians may not be productive as a result of depression, and some of them may go on to attempt and commit suicide. This, he said, will affect the economy.

What can predispose people to depression? Ogbolu said: “In our society things that may predispose include poverty, unemployment, chronic medical conditions especially those poorly controlled and those associated with stigma or are associated with reduced life expectancy, those with substance abuse disorders, harmful cultural practices may also put one at risk such as early marriage and attendant risk of Viscovaginal Fistula (VVF)”, and generally stressful or traumatic life events. There is also a genetic risk. Sometimes you cannot identify any predisposition. These are the same factors that make one susceptible, if they do not have sufficient resilience.”

The psychiatrist said resilience is what protects some against it, while a lack of resilience contributes to susceptibility. He said resilience is a function of many things starting from growing up healthy in a safe and loving family environment, level of immunity, parenting and support, among others.

Ogbolu said the consequences of depression is that it increases one’s risk of having other medical conditions such as heart disease and diabetes, and if one does have these conditions, it can make control more difficult and therefore increase the chance that one will have complications of these diseases which can lead to death. He said it also reduces one’s productivity because of the sever disability associated with it, and this in turn can impoverish one because depression can make one not pursue his or her productive activities. “It is the world’s leading cause of years lived with a disability,” Ogbolu said.

The psychiatrist said suicide is also a consequence. Based on research by Ogbolu and colleagues, over a five-year study period 7.2 per cent of cases referred to psychiatry consultation-liaison services in the LUTH were cases related to suicide.

A community-based study in Nigeria by a consultant psychiatrist at University College Hospital (UCH), Ibadan, Oyo State, Prof. Oye Gureje, and his team of researchers found that in their lifetime about 3.1 per cent of Nigerians will have major depression, and 1.1 per cent will have it in a 12-month period, of which it will be quite severe in about 25 per cent of them.

Dr. Josephat Chinawa and others at the Department of Pediatrics, College of Medicine, University of Nigeria, University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu State, also found that among secondary school students, 2.3 per cent of those aged 10 years and 6.2 per cent of those aged 13 years had moderate depression, and that it was commoner among the girls.

According to a consultant psychiatrist, Dr. Temitope Afolabi, and other researchers, 59.6 per cent of those seen in a family practice setting had depression. There are many other local studies on depression by researchers in Nigeria.

It is believed that a mental health specialist best diagnoses depression definitively, but others, and almost anyone with some training can diagnose it provisionally. Ogbolu said the features are a low mood or sadness that lingers on for about two weeks, together with low or loss energy, sleep problems (usually less or poor sleep that is not refreshing), poor appetite (usually low appetite), loss of interest in the things that used to give pleasure, poor concentration, feeling helpless, worthless, pessimistic about the future, unduly guilty and feeling hopeless, and when severe, the feeling that life is no longer worth living. It is not just one of these that make you depressed but usually a combination of low mood and others.

According to the psychiatrist, depression is very treatable and the treatment is quite effective. It requires patience, as there is no quick fix. Treatment can include drug treatment (which should be handled by a medical doctor trained in mental health), psychological treatment usually using psychotherapy, and social therapy by addressing any social issues that may have contributed to its cause or may delay recovery. The drugs used are of various types and it is best that the doctor finds which suits each case.

Prevention, he said, involves avoiding avoidable stressors in life especially if you have genetic vulnerability, building up resilience, identifying the signs early and addressing them quickly. Having a genetic predisposition does not mean you must come down with depression during your lifetime.

To address the issue, Ogbolu said: “I am the coordinator of the Suicide Research and Prevention Initiative of LUTH and one of the goals is to address disorders like depression which are so closely associated with suicide, through education and information dissemination, and providing hotlines through which those feeling depressed or suicidal can reach us and get help and treatment.”

Ogbolu urged the government to invest more in health and the health budget should ensure that mental health is given the required attention. Also, he said, this government should finally agree to pass the mental health bill that was unsuccessfully presented to the last two national assemblies, to protect the mentally ill (which includes those depressed) and the practitioners.

The psychiatrist said the National Health Insurance Scheme (NHIS) should also review its coverage to include mental health issues at the secondary and tertiary health levels and broaden those currently included at the primary care level.

Ogbolu said there is need for more mental health practitioners, from doctors, to nurses, psychologists, and so on because the number of them available in the country is abysmally low. For instance, he said, there are about 250 psychiatrists in Nigeria to cater for the whole population of over 140 million, and many of them are attracted to other climes due to the general lack of retention of health specialists in the country.

The psychiatrist said the advice to all is to know that no one is immune to depression or other mental health issues. “It could be you. Therefore do not stigmatize those who have mental health issues. Also be supportive and be your brother’s keeper by encouraging anyone you know with the symptoms of depression, to seek treatment or call the hotlines (09080217555, 09034400009, 08111909909, 07013811143) through which members of the public seeking help can reach us,” he said.

According to the World Health Organisation (WHO), although there are known, effective treatments for depression, fewer than half of those affected in the world (in many countries, fewer than 10 per cent) receive such treatments. Barriers to effective care include a lack of resources, lack of trained health-care providers, and social stigma associated with mental disorders. Another barrier to effective care is inaccurate assessment. In countries of all income levels, people who are depressed are often not correctly diagnosed, and others who do not have the disorder are too often misdiagnosed and prescribed antidepressants.

The burden of depression and other mental health conditions is on the rise globally. A World Health Assembly resolution passed in May 2013 has called for a comprehensive, coordinated response to mental disorders at country level.

Prevention programmes have been shown to reduce depression. According to the WHO, effective community approaches to prevent depression include school-based programmes to enhance a pattern of positive thinking in children and adolescents. Interventions for parents of children with behavioural problems may reduce parental depressive symptoms and improve outcomes for their children. Exercise programmes for the elderly can also be effective in depression prevention.

There are effective treatments for moderate and severe depression. The WHO recommends that healthcare providers may offer psychological treatments (such as behavioural activation, cognitive behavioural therapy [CBT], and interpersonal psychotherapy [IPT]) or antidepressant medication (such as selective serotonin reuptake inhibitors [SSRIs] and tricyclic antidepressants [TCAs]). Health-care providers should keep in mind the possible adverse effects associated with antidepressant medication, the ability to deliver both intervention (in terms of expertise, and/or treatment availability), and individual preferences. Different psychological treatment formats for consideration include individual and/or group face-to-face psychological treatments delivered by professionals and supervised lay therapists.

Psychosocial treatments are also effective for mild depression. The WHO said antidepressants can be an effective form of treatment for moderate-severe depression but are not the first line of treatment for cases of mild depression. They should not be used for treating depression in children and are not the first line of treatment in adolescents, among whom they should be used with caution.

Depression is one of the priority conditions covered by WHO’s Mental Health Gap Action Programme (mhGAP). The Programme aims to help countries increase services for people with mental, neurological and substance use disorders, through care provided by health workers who are not specialists in mental health. The Programme asserts that with proper care, psychosocial assistance and medication, tens of millions of people with mental disorders, including depression, could begin to lead normal lives – even where resources are scarce.