AN ASSESSMENT OF THE CURRENT STATUS OF MENTAL ILLNESS IN BENDEL STATE OF NIGERIA: IMPLICATIONS FOR PUBLIC MENTAL HEALTH POLICY AND EDUCATION

This descriptive study assesses the current status of mental illness in Bendel State of Nigeria to determine its implications for mental health policy and education. It is a study of the demographic characteristics of psychiatric patients in the only two modern western psychiatric facilities in Bendel State, the various treatment modalities utilized for mental illness, and the people's choice of therapeutic measures for mental illness in Bendel State.^ This study investigated ten aspects of mental illness in Bendel State (1) An increase of the prevalence of mental illness (psychiatric disorder) in Bendel State. (2) Unaided, unguided, and uncared for mentally ill people roaming about Bendel State. (3) Pluralistic Treatment Modalities for mentally ill patients in Bendel State. (4) Traditional Healers treating more mentally ill patients than the modern western psychiatric hospitals. (5) Inadequate modern western psychiatric facilities in Bendel State. (6) Controversy between Traditional Health and modern western trained doctors over the issue of possible cooperation between traditional and modern western medicine. (7) Evidence of mental illness in all ethnic groups in Bendel State. (8) More scientifically based and better organized modern western psychiatric hospitals than the traditional healing centers. (9) Traditional healers' level of approach with patients, and accessibility to patients' families compared with the modern western trained doctors. (10) An urgent need for an official action to institute a comprehensive mental health policy that will provide an optimum care for the mentally ill in Bendel State, and in Nigeria in general.^ Of the eight popular treatment modalities generally used in Bendel State for mental illness, 54% of the non-patient population sampled preferred the use of traditional healing, 26.5% preferred the use of modern western treatment, and 19.5% preferred religious healers.^ The investigator concluded at this time not to recommend the integration of Traditional Healing and modern western medicine in Nigeria. Rather, improvement of the existing modern western psychiatric facilities and a proposal to establish facilities to enable traditional healing and modern western medicine to exist side by side were highly recommended. ^

Physician coding for mental illness reimbursement and the need for mental health parity

Many patients with anxiety and depression initially seek treatment from their primary care physicians. Changes in insurance coverage and current mental parity laws, make reimbursement for services a problem. This has led to a coding dilemma for physicians seeking payment for their services. This study seeks to determine first the frequency at which primary care physicians use alternative coding, and secondly, if physicians would change their coding practices, provided reimbursement was assured through changes in mental parity laws. A mail survey was sent to 260 randomly selected primary care physicians, who are family practice, internal medicine, and general practice physicians, and members of the Harris County Medical Society. The survey evaluated the physicians' demographics, the number of patients with psychiatric disorders seen by primary care physicians, the frequency with which physicians used alternative coding, and if mental parity laws changed, the rate at which physicians would use a psychiatric illness diagnosis as the primary diagnostic code. The overall response rate was 23%. Only 47 of the 59 physicians, who responded, qualified for the study and of those 45% used a psychiatric disorder to diagnose patients with a primary psychiatric disorder, 47% used a somatic/symptom disorder, and 8% used a medical diagnosis. From the physicians who would not use a psychiatric diagnosis as a primary ICD-9 code, 88% were afraid of not being reimbursed and 12% were worried about stigma or jeopardizing insurability. If payment were assured using a psychiatric diagnostic code, 81% physicians would use a psychiatric diagnosis as the primary diagnostic code. However, 19% would use an alternative diagnostic code in fear of stigmatizing and/or jeopardizing patients' insurability. Although the sample size of the study design was adequate, our survey did not have an ideal response rate, and no significant correlation was observed. However, it is evident that reimbursement for mental illness continues to be a problem for primary care physicians. The reformation of mental parity laws is necessary to ensure that patients receive mental health services and that primary care physicians are reimbursed. Despite the possibility of improved mental parity legislation, some physicians are still hesitant to assign patients with a mental illness diagnosis, due to the associated stigma, which still plays a role in today's society. ^

Understanding mental illness in Nigeria: Bringing culture and traditional medicine into mental health policy

One of the major challenges in treating mental illness in Nigeria is that the health care facilities and mental health care professionals are not enough in number or well equipped to handle the burden of mental illness. There are several barriers to treatment for individual Nigerians which include the following: such as the lack of understanding of the root causes of mental illness, lack of financial support to get mental treatment, lack of social support (family, friends, neighbors), the fear of stigmatization concerning being labeled as mentally ill or being in association with the mentally ill, and the consultation of traditional native healers who may be unknowingly prolonging illness, rather than addressing and treating them due to lack of formal education and standardization of their treatments. Another barrier is the non-health nature of the mental health services in Nigeria. Traditional healers are essentially the mental health system. The elderly, women, and children are the most vulnerable groups in times of strife and hardships. Their mental well-being must be taken into account as well as their special needs in times of personal or societal crisis. ^ Nigerian mental health policy is geared toward forming a mental health system, but in actuality only a mental illness care system is the observed result of the policy. The government of Nigeria has drafted a mental health policy, yet its actual implementation into the Nigerian health infrastructure and society waits to be materialized. The limited health legislation or policy implementations tend to favor those who have access to these urban areas and the facilities' health services. Nigerians living in rural areas are at a disadvantage; many of them may not even be aware of services available to help them understand and treat mental illness. Perhaps, government driven health interventions geared toward mental illness in rural areas would reach an underserved Nigerians and Africans in general. Issues with political instability and limited infrastructure often hinder crucial financial resources and legislation from reaching the people that are truly in need of governmental leadership in regards to mental health policy.^ Traditional healers are a severely untapped resource in the treatment of mental illness within the Nigerian population. They are abundant within Nigerian communities and are meeting a real need for the mentally ill. However, much can be done to remove the barriers that prevent the integration of traditional healers within the mental health system and improve the quality of care they administer within the population. Mental illness is almost exclusively coped with through traditional medicine practices. Mobilization and education from each strata of Nigerian society and government as well as input from the medical community can improve how traditional medicine is utilized as a treatment for clinical illness and help alleviate the heavy burden of mental illness in Nigeria. Currently, there is no existing policy making structure for a working mental health system in Nigeria, and traditional healers are not taken into account in any formulation of mental health policy. Advocacy for mental illness is severely inadequate due to fear of stigmatization, with no formally recognized national of regional mental health association.^

The association between mental health and hypertension in the 2005 Department of Defense Population Survey

Major objectives within Healthy People 2010 include improving hypertension and mental health management of the American population. Both mental health issues and hypertension exist in the military which may decrease the health status of military personnel and diminish the ability to complete assigned missions. Some cases may be incompatible with military service even with optimum treatment. In the interest of maintaining a fit fighting force, the Department of Defense regularly conducts a survey of health related behaviors among active duty military personnel. The 2005 DoD Survey was conducted to obtain information regarding health and behavioral readiness among active duty military personnel to assess progress toward selected Healthy People 2010 objectives. ^ This study is a cross-sectional prevalence design looking at the association of hypertension treatment with mental health issues (either treatment or perceived need for treatment) within the military population sampled in the 2005 DoD Survey. There were 16,946 military personnel in the final cross-sectional sample representing 1.3 million active duty service members. The question is whether there is a significant association between the self-reported occurrence of hypertension and the self-reported occurrence of mental health issues in the 2005 DoD Survey. In addition to these variables, this survey examined the contribution of various sociodemographic, occupational, and behavioral covariates. An analysis of the demographic composition of the study variables was followed by logistic analysis, comparing outcome variables with each of the independent variables. Following univariate regression analysis, multivariate regression was performed with adjustment (for those variables with an unadjusted alpha level less than or equal to 0.25). ^ All the mental health related indicators were associated with hypertension treatment. The same relationship was maintained after multivariate adjustment. The covariates remaining as significant (p < 0.05) in the final model included gender, age, race/ethnicity and obesity. There is a need to recognize and treat co-morbid medical diagnoses among mental health patients and to improve quality of life outcomes, whether in the military population or the general population. Optimum health of the individual can be facilitated through discovery of treatable cases, to minimize disruptions of military missions, and even allow for continued military service. ^

The association between mental health and cigarette smoking in active duty military members

Previous research has shown an association between mental health status and cigarette smoking. This study examined four specific mental health predictors and the outcome variable any smoking, defined as smoking one or more cigarettes in the past 30 days. The population included active duty military members serving in the United States Army, Air Force, Navy and Marine Corps. The data was collected during the 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel, a component of the Defense Lifestyle Assessment Program. The sample size included 13,603 subjects. This cross sectional prevalence study consisted of descriptive statistics, univariate analysis, and multivariate logistic regression analysis of the four mental health predictors and the any smoking outcome variable. Multivariate adjustment showed an association between the four mental health predictors and any smoking. This association is consistent with previous literature and can help guide public health officials in the development of smoking prevention and cessation programs.^

Air Force Web Preventive Health Assessment (AF WEBPHA) mental health screening effectiveness

The U.S. Air Force assesses Active Duty Air Force (ADAF) health annually using the Air Force Web-based Preventative Health Assessment (AF WebPHA). The assessment is based on a self-administered survey used to determine the overall Air Force health and readiness, as well as, the individual health of each airman. Individual survey responses as well as groups of responses generate further computer generated assessment and result in a classification of 'Critical', 'Priority', or 'Routine', depending on the need and urgency for further evaluation by a health care provider. The importance of the 'Priority' and 'Critical' classifications is to provide timely intervention to prevent or limit unfavorable outcomes that may threaten an airman. Though the USAF has been transitioning from a paper form to the online WebPHA survey for the last three years it was not made mandatory for all airmen until 2009. The survey covers many health aspects including family history, tobacco use, exercise, alcohol use, and mental health. ^ Military stressors such as deployment, change of station, and the trauma of war can aggravate and intensify the common baseline worries experienced by the general population and place airmen at additional risks for mental health concerns and illness. This study assesses the effectiveness of the AF WebPHA mental health screening questions in predicting a mental health disorder diagnosis according to International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes generated by physicians or their surrogates. In order to assess the sensitivity, specificity, and positive predictive value of the AF WebPHA as a screening tool for mental health, survey results were compared to ascertain if they generated any mental health disorder related diagnosis for the period from January 1, 2009 to March 31, 2010. ^ Statistical analysis of the AF WebPHA mental health responses when compared with matching ICD-9-CM codes found that the sensitivity for 'Critical' or 'Priority' responses was only 3.4% and that it would correctly predict those who had the selected mental health diagnosis 9% of the time.^