A Review of Stigma and Mental Illness in Nigeria

As defined by the Oxford-Unabridged Dictionary “stigma” is a mark of “infamy, disgrace, or reproach” its derived from the Latin “tattoo, indicating slave or criminal status”; originating from stizein, the Greek word for “a recognizable sign made by burning or cutting a part of the skin of a less valued member of society with an aim of distinguishing him/her from the rest of the members”, (Oxford Unabridged Dictionary) [1]. Borne by fear and ignorance, and not unlike the shackles of an individual mind and communal spirit that vilified pre-modern victims of medical scourge that now routinely and with clinical disinterest rendered inconsequential in clinics throughout the world, fear borne of ignorance engenders stigmatization of mental illness, [2]. It encourages denial among the mentally ill and many who are committed to their best interest [3]; it unduly cautions victims of mental illness against seeking and abiding proven treatment [4,5]; and it discourages well intended and otherwise highly-qualified practioner from addressing a debilitating medical condition with clients who may have no other realistic point of contact with the medical establishment, than for example, a traditional health provider [2].


Introduction
As defined by the Oxford-Unabridged Dictionary "stigma" is a mark of "infamy, disgrace, or reproach" its derived from the Latin "tattoo, indicating slave or criminal status"; originating from stizein, the Greek word for "a recognizable sign made by burning or cutting a part of the skin of a less valued member of society with an aim of distinguishing him/her from the rest of the members", (Oxford Unabridged Dictionary) [1].Borne by fear and ignorance, and not unlike the shackles of an individual mind and communal spirit that vilified pre-modern victims of medical scourge that now routinely and with clinical disinterest rendered inconsequential in clinics throughout the world, fear borne of ignorance engenders stigmatization of mental illness, [2].It encourages denial among the mentally ill and many who are committed to their best interest [3]; it unduly cautions victims of mental illness against seeking and abiding proven treatment [4,5]; and it discourages well intended and otherwise highly-qualified practioner from addressing a debilitating medical condition with clients who may have no other realistic point of contact with the medical establishment, than for example, a traditional health provider [2].
Persons with mental illness often have to struggle with double problem.First, they have to cope with the symptoms of the disease itself; depending on the particular mental disorder they may be having problems such as recurrent hallucinations, delusions, anxiety or mood swings.These symptoms can make it difficult for someone with mental illness to work, live independently or achieve a good quality of life.Secondly, the misunderstandings of society about the various mental disorders results in stigma.Some persons who manage their mental illness well enough to work still have tremendous difficulties finding a job because employers discriminate against them.Thus, mental illness results not only in the difficulties arising from the symptoms of the disease but also in the disadvantages associated with societal reactions.As further complication, some people with mental illness may accept the common prejudices about mental illness; turn against themselves, and lose-confidence [6].
Stigmatization deprives victims of mental illness their full measure of human dignity and participation in wider society [7] by undermining social support and compromising opportunity for treatment.And this is done by individual and institutional discrimination resulting from misconception [8], prejudicial stereotypes [9] and negative public and professional attitudes about mental illness [10].Widely shared prejudicial attitudes towards schizophrenia, alcoholism and other substance use disorders continue to stigmatize victims of those illnesses [11].Although such negative attitudes are somewhat less widely held by psychiatric care providers, studies indicate significant negativism among other health care professionals.A national survey on stigma and mental illness among nursing professionals in Nigeria conducted in the six geopolitical zones of the country by Obembe et al. [12] reported that 40% of their studied population viewed mentally ill individuals as violent, 26.5% would distance themselves from the mentally ill and a third associated mental illness with lack of self discipline and will power but generally they held less negative views about mental illness.Another study conducted by Abasiubong [13] on stigmatizing attitudes towards the mentally ill in a Nigerian university teaching hospital among the hospital population found that 52% of the respondents believed witches were responsible for the causation of mental illness, 44.2% thought it was due to demon possession, and close to one third felt it was due to the consequences of divine punishment.The respondents generally held strong negative views about the mentally ill.Most of the respondents believed being authoritarian and restrictive in their attitudes towards the mentally ill and placing emphasis on custodial care is the best approach to treatment.
Several individuals within the general public/communities assume that persons with psychotic disorders are unpredictable and incapable of being managed, even by the best efforts of the health system , and therefore are considered a threat to the social order and to public safety [14].A study in Karfi village in northern Nigeria by Kabir et al. [15] reported most common symptoms proffered by respondents as manifestations of mental illness include aggression/destructiveness (22.0%), loquaciousness (21.2%), eccentric behavior (16.1%) and wandering (13.3%).Drug misuse including alcohol, cannabis, and other street drugs was identified in 34.3% of the responses as a major cause of mental illness, followed by divine wrath/ God's will (19%), and magic/spirit possession (18.0%).About 46% of respondents preferred orthodox medical care for the mentally sick while 34% were more inclined to spiritual healing.Almost half of the respondents harbored negative feelings towards the mentally ill.Literate respondents were seven times more likely to exhibit positive feelings towards the mentally ill as compared to non-literate respondents.Gureje et al. [16] studied to determine the knowledge and attitudes of a representative community sample in Nigeria and reported poor knowledge about the causes of mental illness with wide spread negative views about the mentally ill people; 96.5% of their studied sample believed that people with mental illness are dangerous because of their violent behaviours.Sociodemographic predictors for both knowledge and intolerant attitudes were few in their study.A report by Audu et al. [17] in a rural in Northern Nigeria found widespread ignorance about causation, mode of transmission and remedies available for mental illness as a cause for stigmatizing the mentally ill, with only 0.9% of respondents attributing mental illness to brain disease.The others mental illness to spiritual attack, punishment for evil doing and illicit psychoactive substance use, among other things.Negative views about the mentally ill were also widely expressed resulting in discriminatory practices.
There is wide spread stigma and discrimination among the mentally ill in Nigeria even in population that are expected to be enlightened in this aspect.Although the national survey reported less strong negative views, it appears to correlate with period of exposure to psychiatry training period.The wide spread belief in supernatural causation of mental illness is likely to add to the difficulties of designing an effective anti-stigma psycho-education programme in Nigeria.There is need to develop strategies in Nigeria to change stigma attached to mental illness both institutional and at the community level.

Efforts for Reducing Stigma in Nigeria
Issues of mental health have been a great concern to the public in several parts of the world.As many as 450 million people at any given time worldwide are estimated to be suffering from some form of brain or mental disorder which includes substance abuse and behavioural disorders [18].However, despite the overwhelming prevalence of mental disorders, more than 30% of countries do not have mental health policies or mental health programmes [18].In Nigeria, mental health services are not readily available to the citizens, due to their concentration in the urban areas with majority of the Nigerian populace residing in the rural areas.The first mental health policy was formulated in 1991 in Lagos, Nigeria which is yet to become a policy.In 2007, the World Health Organization reported that 20 percent of Nigerians suffer from mental disorders, which means million people are suffering from mental disorders in a country with a population of 160 million which is quiet huge [18].Despite these huge rates of mental disorders, little has been done to raise awareness about such issues or to address the stigma and discrimination associated with mental illness.For this reason Beautiful Mind and Wellness Foundation (BMWF) was established as a nongovernmental/non-profit organization to provide awareness on mental health issues in Ghana and Nigeria, with its location in West Africa.This organization provides awareness through advocacy, education, and evidence-based treatment interventions.BMWF is the forefront on mental health prevention and intervention through education and training with efforts to increase awareness and reduce stigma and discrimination in Nigeria and Ghana.The foundation is client focused and tailored towards cultural preference of those it serves.The program started in December 2012, and it offers anti-stigma and social inclusion education through seminars to train families, communities and general population on mental health symptoms, management, and prevention [18].Community based mental health education, group sessions and training for community and traditional leaders is also provided.
In its bid to ensure the mental wellbeing of its citizens, the Lagos government in Nigeria has committed to a mental health policy which seeks to combat stigma and discrimination against groups and individuals with mental health problems.Part of the recommendation is the expansion and improvement of the current systems of mental health delivery in Lagos state, provision of cost effective interventions and effective care, enhancing human resources, establishing national health policies, programmes and legislation.Encouraging communities, families and users to be involved and engaged in the reduction of stigma and discrimination.
In Edo state, Nigeria efforts are made through using radio and television to provide friendly platforms for people so as to interact, with the intension of sensitizing and mobilizing others to collectively or individually support social causes of mental illness [19].Though their potentials are yet to be explored fully in terms of programming, social responsibilities as well as maintaining good public outlook, the media assists a lot in the fight against stigma in this state.Efforts are made to carefully design programmes on radios and televisions so as to encourage and support the mentally ill individuals and NGO's caring for such individuals.Managers working in media houses in Edo state and other parts of Nigeria are also encouraged to design and mount interactive programmes on radio and television with the aim of reducing mental health stigma.Individuals are also encouraged to "speak up and speak out" about mental health challenges they or their loved ones may be facing or visit mental health services for assistance [19].

Way Forward in Nigeria
• Provision of advocacy and other groups to target stigma in a deliberate attempt to assist in improving people with severe mental illness.For example, the National Alliance for the Mentally Ill (NAMI) is a grass root group of family members and people with severe mental illness; it has made combating stigma a top priority for its 172,000 members, [20,21].They the "Campaign to End Discrimination" in 1995 as a concerted effort to diminish stigma.The National Mental Health Association, a mental health advocacy group, has been educating the public about mental illness for more than 90 years.There is also The National Stigma Clearinghouse, who aggressively responds to negative images of mental illness, and also communicates with media about the positive aspects of mental illness [3].
• To encourage government agencies to join the fray to empower consumers and fund projects that attempt to discount stigma.Psychiatric hospitals across the country should employ consumer advocates whose job will require vigilance to misrepresentations of mental health issues.Also private citizens to be encouraged to show concern about stigma and assist in any way possible to combat the trend.Example, Rotary International inaugurate "Erase the Stigma" a campaign to educate American business leaders about the truth and misconceptions of severe mental illness.
• Education and information programs that will address and provide understanding of mental illness using books, videos, slides and other audio-visual aids to highlight false assumption about groups (violence among mentally ill persons) to be provided across the country.Several studies have examined the effects of education on mental illness stigma indicating that persons who have better understanding of mental illness are less likely to endorse stigma and discrimination [22,23].Others show that participation in brief courses on mental illness and treatment lead to improved attitudes about persons with mental illness [24][25][26].