The time is now: reforming Nigeria's outdated mental health laws

Nigeria's mental health legislation was first enacted in 1916 and was called the Lunacy Ordinance. In 1958, these laws were amended to give medical practitioners and magistrates the power to detain an individual suffering from mental illness.1Westbrook AH Mental health legislation and involuntary commitment in Nigeria: a call for reform.https://openscholarship.wustl.edu/cgi/viewcontent.cgi?article=1022&context=law_globalstudiesDate: 2011Date accessed: June 17, 2020Google Scholar Renamed the Lunacy Act of 1958, these laws have not been amended since.2Kingdon D Lunacy Act: the laws of the Federation of Nigeria and Lagos Nigeria. the revised edition. Eyre and Spottiswoode, London1958: 2290-2307Google Scholar Today, this legislation is outdated and archaic, reflective of a period in human history not only when mental health was severely misunderstood but also when the treatment of people with mental health-care needs was both inhumane and ineffective. In 2003, a Mental Health Bill was put forward to the National Assembly of Nigeria. With little support and no progress for more than 6 years, it was withdrawn in April, 2009. This Bill was presented again in 2013, when the National Policy for Mental Health Services Delivery set out the principles for the delivery of care to people with mental, neurological, and substance abuse problems.3Federal Ministry of HealthNational policy for mental health services delivery.https://cheld.org/wp-content/uploads/2015/02/national_policy_for_mental_health_service_delivery__2013_.pdfDate: August, 2013Date accessed: June 17, 2020Google Scholar Again, facing scant support, it has yet to become law. In the absence of a dedicated authority to assess compliance or support legislation, the effect of this policy on the quality of care and life for people living with mental health problems in Nigeria remains negligible. Nigeria currently faces a global human rights emergency in mental health. Underpinned by poor societal attitudes towards mental illness and inadequate resources, facilities, and mental health staff, figures suggest that approximately 80% of individuals with serious mental health needs in Nigeria cannot access care.4Demyttenaere K Bruffaerts R Posada-Villa J et al.Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys.JAMA. 2004; 291: 2581-2590Crossref PubMed Scopus (2264) Google Scholar With fewer than 300 psychiatrists for a population of more than 200 million, most of whom are based in urban areas, and in view of poor knowledge of mental disorders at the primary health-care level, caring for people with mental illness is typically left to family members.5Odejide AO Morakinyo JJ Oshiname FO Omigbodun O Ajuwon AJ Kola L Integrating mental health into primary health care in Nigeria: management of depression in a local government (district) area as a paradigm.Seishin Shinkeigaku Zasshi. 2002; 104: 802-809PubMed Google Scholar A paucity of community-based and primary health-care services means that access to care is restricted to the most severe cases, usually in the form of psychiatric inpatient care or makeshift institutions. The result is a chronically and dangerously under-resourced mental health system catering to the needs of an estimated one in eight Nigerian people who suffer from mental illness,3Federal Ministry of HealthNational policy for mental health services delivery.https://cheld.org/wp-content/uploads/2015/02/national_policy_for_mental_health_service_delivery__2013_.pdfDate: August, 2013Date accessed: June 17, 2020Google Scholar poor awareness of the causes of mental health, widespread stigma and discrimination, poorly equipped services, and abuse of people with mental health problems. A reform of the mental health law that is in keeping with international standards is urgently needed to drive change. The global target of WHO's mental health action plan6WHOMental health action plan 2013–2020.https://www.who.int/mental_health/publications/action_plan/en/Date: 2013Date accessed: June 17, 2020Google Scholar aims for 50% of countries to have developed or updated their law in line with international and regional human rights instruments by 2020. In 2017, only 40% of WHO member states had updated their legislation in the previous 5 years (ie, since 2013).7WHOMental health atlas.https://www.who.int/mental_health/evidence/atlas/mental_health_atlas_2017/en/Date: 2017Date accessed: June 17, 2020Google Scholar Africa had the lowest rate at 21%, although this rate had doubled since 2014. On Feb 19, 2020, the Nigerian Senate held a public hearing for the Mental Health and Substance Abuse Bill. If passed, the Bill would allow for much needed budgetary allocations for mental health facilities and mental health providers. The time is now for a mental health legislation and policy in Nigeria to protect individuals suffering from mental illness from being subjected to gross human rights violations, including degrading treatment and destitute living conditions.8Human Rights WatchNigeria: people with mental health conditions, chained, abused.https://www.hrw.org/news/2019/11/11/nigeria-people-mental-health-conditions-chained-abusedDate: Nov 11, 2019Date accessed: June 17, 2020Google Scholar Widespread consultation with key stakeholders, including the Association of Psychiatrists of Nigeria and community representatives, is currently in process. In strong support of this Bill, we further put forward several considerations. Specifically, we call for any resulting legislation to be in accordance with the WHO Checklist on Mental Health Legislation to ensure that it meets international standards. Second, legislation should be culturally sensitive and meet the human rights standards as set out by the International Covenant on Economic, Social and Cultural Rights9UN Human Rights Office of the High CommissionerInternational Covenant on Economic, Social and Cultural Rights.https://www.ohchr.org/en/professionalinterest/pages/cescr.aspxDate: Jan 3, 1976Date accessed: June 17, 2020Google Scholar and the African Charter on Human and Peoples' Rights.10UNAfrican Charter on Human and Peoples' Rights.https://treaties.un.org/doc/Publication/UNTS/Volume%201520/volume-1520-I-26363-English.pdfDate: Dec 28, 1988Date accessed: June 17, 2020Google Scholar Third, we call for mental health services to be a covered mandate in the national health insurance scheme to ensure accessibility and affordability of care. Fourth, and in line with best practice, we urge additional support for outpatient, primary, and community care services for people with mental illness. Finally, and in view of the severe dearth of human resources for mental health, we call for the integration of mental health training, responses, and psychoeducation within primary care settings, as contained in the National Mental Health Service Delivery Policy of Nigeria. Legislation that works for all is important to help improve the health of the nation and to safeguard the care of all Nigerian people, today and for the future. OU, NM, SAL, and FV conceptualised and drafted the Comment. CA and TLS provided useful insight to finalise the Comment. TLS participated in the development of Mental Health Service Delivery Policy for Nigeria and is a member of the committee working on the National Mental Health Bill, currently in the legislative process to be passed into law by the Nigerian National Assembly. CA is a member of the Nigerian National Assembly. OU, NM, SAL, and FV declare no competing interests.