A Nigeria Hospital Tackles Mental Illness

A hospital’s community approach to mental health might be a model for Africa healthcare.

A Nigeria hospital’s community approach to mental health might be a model for improving access to healthcare across Eastern Africa.
“Over the past two decades, we’ve had a sustained vision to take mental healthcare beyond the walls of the hospital,” says Dr. Timothy Olaolu Adebowale, the acting provost and medical director of Neuropsychiatric Hospital, Aro. Photo from Kaizenify

In Nigeria, if you listen to the radio, attend community theater performances, or eavesdrop on market chatter, you might hear the name “Aro” come up. But Aro is not a pop star, athlete or politician — it is a neuropsychiatric hospital that’s winning a lot of fans in Africa and recognition from healthcare experts around the world.

Mental health treatment remains out of reach for many in Nigeria and in much of Africa. “People go to the hospital and they try to get the best they can afford with the money they can find,” says Dr. Oye Gureje, a professor of psychiatry at the University of Ibadan in western Nigeria. Patients typically pay for services on their own, because few have public insurance. And that’s if they have the nerve to go to begin with — mental health issues in Nigeria, as in many places, are a source of stigma and even disgrace.

Aro — more formally called Neuropsychiatric Hospital, Aro — is on a mission to change both the conversation around mental health and its overall availability. Based in the Ogun state capital of Abeokuta, Aro is the country’s first psychiatric-care hospital built and operated entirely with government funding. Opened in 1954, after operating under the same name as an asylum at a different location for ten years, the hospital today serves about 30,000 patients a year and 250 to 300 new patients each month, according to Dr. Timothy Olaolu Adebowale, the hospital’s acting provost and medical director. Most patients hail from Nigeria, with some from neighboring West African countries and others from the U.S. and Europe.

Since 2005, the hospital has run an extensive campaign to raise awareness about different forms of mental illness and how Aro can help individuals cope with different disorders. “We are really attempting to dilute the stigma,” says Adebowale. The hospital’s campaign has included spots on local television and radio stations, public drama presentations, and community talks with artisans, students and women who work as vendors at local markets. “The activities resulted in a significant increase in service utilization at the base hospital,” he says.

Many of Aro’s campaigns emphasize the availability and efficacy of Western medicine-based treatment, countering deep cultural traditions that see mental illness as a problem best battled with religious and herbal remedies. For example, Alege Olusegun Edmund, a principal nursing officer at Aro for 11 years, hosts a radio program that broadcasts to southwestern Nigeria, and works to educate people on the causes of mental health issues and to encourage individuals to seek professional treatment. Alege says that this and other awareness programs have helped increase the number of patients the hospital sees. “Hospital management now considers such campaigns to be an essential part of the hospital’s activities,” says Alege.

Today, clients come to the hospital for both inpatient and outpatient care in general adult psychiatry — its most common service — as well as for substance abuse treatment, child and adolescent mental health, forensic psychiatry, psychogeriatric services and psychological interventions. The hospital employs a combination of talk therapy, pharmacotherapy, electroconvulsive therapy and occupational therapy. Oyinade Tomori, the hospital’s assistant director of library and information services, said in an email that inpatients are admitted to open wards where they can receive meals, nursing care and a multidisciplinary team intervention. After recovery, patients are granted a trial leave for three months, then are released to outpatient care with scheduled follow-up appointments and medication review.

The hospital was the first psychiatric hospital in the country to establish a rehabilitation unit for long stay patients, using therapeutic and vocational interventions and a transitional hostel (commonly known as a “half-way house”). Tomori said the end result is a strong biopsychosocial approach to treatment, with emphasis on family involvement and a tradition of transparency and consistent community participation.

Aro’s reputation for having a culture of client-centered approaches earned it the prestigious 2015 national Nigerian Healthcare Excellence Award for best primary care provider, which recognizes outstanding service delivery in the field of healthcare in Nigeria. The United Nations’ Office on Drugs and Crime has cited the hospital as a leading center for substance abuse treatment in West Africa. “Our patients say we have a different touch,” Adebowale says. “Our vision is to be a national center of excellence and an international point of reference in mental health.”

To help integrate the care of mental health into the broader public world, Aro’s leadership has expanded services and begun offering general medical care to the surrounding community. “Over the past two decades, we’ve had a sustained vision to take mental healthcare beyond the walls of the hospital,” says Adebowale. The mission is to incorporate other services that will bring non-mentally ill individuals into the hospital. “This has changed the traditional perception of the hospital,” he says.

In a further effort to destigmatize the work being done there, many of the hospital’s amenities — including a gym, physiotherapy services, guesthouses and a football pitch — have been made available for public use. “The ultimate goal was the establishment of the community family medicine clinic, manned by a consultant family physician,” says Adebowale. “These anti-stigma strategies had a major achievement in 2011, when the first baby delivery was taken in the hospital.” Broadening the scope of the hospital complex was working: People were beginning to see the hospital in a new light.

At the same time that Aro has been working to break down the stigmas around mental health, it has come up with innovative ways to deliver mental health services more broadly and more inexpensively. In 2011, it launched the Aro Primary Care Programme, a service to expand mental healthcare beyond its walls. “This is the first successful mental health primary care integration effort in the country,” says Adebowale. The program integrates mental health services into primary care facilities across the 20 local government areas in Ogun state. The vision is that, to reach as many people as possible, mental health services can be first assessed by primary care healthcare professionals and other health providers in the field.

Professor of psychiatry Gureje, who also serves as the director of the WHO Collaborating Centre for Research in Mental Health, Neurosciences and Substance Abuse at the University of Ibadan, says this outreach strategy has many advantages. “This is a task-sharing approach to scaling up service,” he says. “It has been shown to be an effective and efficient way of increasing mental health service coverage in a number of low- and middle-income countries, including Nigeria. The service is cost-effective and delivered in less stigmatizing settings.”

For all the help it offers, the Aro Primary Care Programme can’t by itself solve a bigger national problem: the deficit of trained mental healthcare professionals in Nigeria. Tomori noted that in a nation of 186 million people, there is only one psychiatrist for one million citizens, and 0.16 nurses for every 100,000 people. To help grow the numbers of mental healthcare professionals, Aro began offering post-graduate residency programs and other research activities in the 1980s and is currently affiliated with the Olabisi Onabanjo University, Ago-Iwoye.

“We have about 26 resident doctors with specialized training in psychiatry, and we are training more," says Adebowale, who personally oversaw training at the hospital for several years. Nurses also receive basic psychiatric training after their first-level nursing instruction, and the hospital produces about 50 trained nurses each year. “Nurses from other institutions come to the hospital for clinical experience training,” adds Adebowale, “and most psychiatrists in Nigeria have come to the hospital for training.” Increasing educational opportunities and training more mental health professionals is crucial to increasing access to care, he says.

Gureje says that until more mental health professionals are trained nationally, Aro’s strategy of providing more people with mental health treatment through primary care visits is a necessary fall-back. “The way to bring service to those in need will have to be by empowering non-specialist health providers to deliver basic essential care for the most common mental health conditions,” he says. In the long run, though, top-notch mental-health care will require more specialists — and more facilities like Aro.

 

— Cheryl Alkon

Cheryl Alkon is a freelance writer based in Natick, Massachusetts.

 

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