Correctional psychiatry in Nigeria: dynamics of mental healthcare in the most restrictive alternative.

Nigeria has poorly structured services for correctional mental health driven by a mix of socioeconomic and legal factors. The archaic asylum systems established in the early part of the 20th century under the Lunacy ordinance of 1916 are no longer fit for purpose. The present strategy is to provide mental healthcare for mentally abnormal offenders within some prisons in the country. The current models for this are poorly staffed and underfunded. Adoption of task-shifting approaches based on evidence-based strategies within the context of professional innovation, government commitment and international collaboration should help to develop and sustain the needed correctional psychiatry services.

Profile of clinically-diagnosed dementias in a neuropsychiatric practice in Abeokuta, south-western Nigeria.

OBJECTIVE: Many subjects with dementia present primarily to neuropsychiatric practices because of behavioural and psychological symptoms (BPSD). This study reviewed the profile of clinically-diagnosed dementias and BPSD seen in a pioneer neuropsychiatric practice in Abeokuta, southwestern Nigeria over a ten year period (January1998 - December 2007). METHODS: A review of hospital records of all patients with diagnoses of dementia or dementing illness using the ICD-10 criteria as well as specific diagnostic criteria for different dementia phenotypes. Associated BPSD, co-morbidities and treatments were also reviewed. RESULTS: Out of a total of 240,294 patients seen over the study period, 108 subjects met clinical diagnostic criteria for probable dementia giving a hospital frequency of 45 per 100,000. Alzheimer's disease (AD) and Vascular dementia (VaD) were the predominant phenotypes seen in 62 (57.4%) and 18 (16.7%) subjects respectively. Others include mixed dementia (4 cases), frontotemporal dementia (4 cases), Lewy body dementia (3 cases), alcohol-related dementia (3 cases), PD dementia (1 case) and unclassifiable (13 cases). Apathy, night time behaviour, aberrant motor behaviour, agitation and irritability were the most common BPSD features, while hypertension was the most common co-morbidity. Neuroleptics, anticholinergics and anti-hypertensives were most commonly prescribed. Anticholinesterase inhibitors were sparingly used. CONCLUSION: Probable AD was the most prevalent dementia phenotype seen in this practice. Increased awareness of dementia and better utilization of specific treatments are needed among psychiatrists and primary care practitioners in Nigeria.

Financial cost of treating Nigerian in-patients with schizophrenia.

Fifty seven each ofhospitalised schizophrenic patients (fulfilled diagnostic criteria for research version of I.C.D. 10) and diabetic patients respectively, matched for age and sex, were followed up from admission to discharge (July 1997 - December 1997). B.P.R.S. was used to measure the severity of psychopathology at admission and discharge for the former, while the levels of blood glucose at admission and discharge were assessed for the latter. Also, interviewed during the study were 374 relatives comprising 102 and 272 relatives of schizophrenic and diabetic patients respectively. Weekly assessments of cost of treatment were done from admission to discharge using the proforma which took cognisance of aspects of direct and indirect costs for patients and relatives of both groups. Schizophrenic patients had a poorer employment record (P = 0.000), more diabetic patients were married (P = 0.000), relatives shouldered the financial burden of care of more schizophrenic patients (P = 0.000), more schizophrenic patients travelled over an average of 122 km to reach the hospital whereas diabetic patients travelled averagely 19.8 km (P = 0.000) and the mean duration of admission for schizophrenic patients was significantly longer (P = 0.000). The mean monthly income for diabetic patients was significantly higher than for schizophrenic patients (P = 0.000), and the mean direct cost for schizophrenia per admission 9882.00 Naira was significantly higher than that of diabetes mellitus 7892.00 Naira (P = 0.000). The mean indirect cost for schizophrenic patients per admission which is 3604.00 Naira did not differ significantly from that of diabetic patients of 1488.00 Naira (P = 0.288). The mean total cost of schizophrenia per admission--is 11,337.00 Naira and was significantly higher than for diabetes 8571.00 Naira (P = 0.000). However, the mean direct cost per week for diabetes mellitus 4494.00 Naira was significantly higher than for schizophrenia 1011.00 Naira (P = 0.00). The mean indirect cost for diabetes mellitus per week 406.00 Naira did not differ significantly from that ofschizophrenia 168.00 Naira (P = 0.602). The mean total cost of diabetes mellitus per week 4910.00 Naira was significantly higher than for schizophrenia 1235.00 Naira (P = 0.000). Cost of medication ranked highest in all items of cost for both the schizophrenic and diabetic cohorts. The implications of the findings on clinical practice in Nigeria and our current socio-economic scenario (especially with regard to schizophrenic patients and their families) are discussed. The need to reinforce the socio-economic support from government and the larger society for schizophrenic patients and their families is highlighted.

Beliefs and knowledge about aetiology of mental illness among Nigerian psychiatric patients and their relatives.

A survey of 70 insightful clinically stable out-patients with functional psychotic disorders and 70 accompanying relatives was carried out. They were interviewed about their beliefs concerning the cause of the illness, and their awareness of other possible aetiological factors. Relevant sociodemographic and clinical information were also elicited. Twelve (17.1%) patients and relatives, respectively, gave "medical" causal explanations; 16 (22.9%) patients and 13 (18.6%) relatives gave "psychosocial" causal explanations; 27 (38.6%) patients and 38 (54.3%) relatives were "uncertain" about the cause of their/relatives' illness (X2 = 5.08; df = 3: P = 0.16). Relatives reported a greater relevance of "heredity" (X2 = 11.58; P = 0.0006) and "supernatural" factors (X2 = 4.72: P = 0.029) as other possible causal factors, than patients. Patients with previous psychiatric hospitalisation reported higher prevalence of "psychosocial" and "supernatural" causal beliefs than those without (X2 = 9.15; P = 0.027). Also, patients with "medical" causal belief reported better treatment compliance than those with other beliefs (P = 0.031). Among relatives, "psychosocial" causal belief in comparison with other beliefs was associated with a longer duration of treatment in the hospital (h = 8.29; P = 0.04). For patients, knowledge about possible causal role of "heredity was significantly more prevalent among male than female patients (X2 = 6.55; P = 0.01) and admission of possible "supernatural" causation was associated with education below the secondary level (X2 = 6.68; P = 0.008). For relatives, knowledge about possible causal role of brain dysfunction was associated with longer duration of treatment (u = 3.93; P = 0.047), and knowledge of possible causal role of "psychosocial" stress was associated with urban place of residence rather than rural (X2 = 10.52; P = 0.0012). For both patients and relatives, the most acceptable aetiological proposition was the "supernatural" while the least was "psychosocial". Findings revealed, among others, the widespread belief in "supernatural" causation of mental illness in patients/relatives. Some identified significant findings may be relevant in mental health education programme development.

Prevalence of psychiatric morbidity among convicted inmates in a Nigerian prison community.

Studies of psychiatric morbidity in Nigerian prisons have not involved assessment for specific psychiatric disorders. The general aim of this study was to highlight the prevalence of psychiatric morbidity among convicted inmates at a medium security prison in Nigeria. In a one month period in 1996, 100 inmates (93% males, mean age, 31.4 years) of the prison in Benin City, were assessed, using the General Health Questionnaire (GHQ-30) and the Psychiatric Assessment Schedule (PAS). The 34 subjects who scored upto GHQ-30 cut-off, four, had specific axis I DSM III-R diagnoses, including, schizophrenia in two, major depression in two in recurrent mild depression in twenty one, generalised anxiety disorder in eight and somatisation disorder in one. On axis II, six subjects had antisocial personality disorder while another subject had probable mild mental retardation. On Axis III, 15 subjects had chronic physical illnesses, including one with epilepsy. Twenty five inmates had past histories of drug abuse prior to imprisonment, including cannabis (11%) and alcohol (13%). Total PAS scores were significantly predicted only by GHQ scores and length of stay in prison. There was no association between offence committed and psychiatric morbidity. Most subjects with psychiatric morbidity developed these illnesses while in prison. The findings differed from the situation in developed countries where personality disorders and substance use are much more prevalent. The fairly high level of psychiatric disorders underscores the need to improve medical services in the prison.

Psychoactive substance abuse among inmates of a Nigerian prison population.

The objectives of the study were: (1) to assess the prevalence rate of psychoactive substance use and dependence among inmates of a Nigerian prison population within the past month; (2) to highlight how aware these prisoners were, of the various drugs of abuse; (3) to compare the findings with those of reports from abroad, and general Nigerian population samples. In mid-1995, 395 subjects (97.5% males, mean age 30.5 years) were interviewed, with a questionnaire that contained DSM-III-R criteria for dependence. About two-thirds were those on remand or awaiting trial, and the majority (70%) were accused of theft and armed robbery. Compared with Nigerian general population samples, the cohort had much higher prevalence rates of awareness and life-time use of psychoactive substances. Cannabis was the only drug regularly abused in the past month, by 26 (6.6%) subjects (all males); out of whom 11 (42.3%) satisfied DSM-III-R criteria for dependence. Use of intravenous drugs was not evident. This pattern differed markedly from the situation in industrialised countries. Cannabis abuse was significantly associated with those in prison for less than six months and on a charge of theft/armed robbery.

Angiotensin converting enzyme insertion/deletion polymorphism: association with ethnic origin.

OBJECTIVE: To determine the distribution of the insertion/deletion (I/D) polymorphism of the angiotensin converting enzyme (ACE) gene in several ethnic groups: Caucasian Europeans, Black Nigerians, Samoan Polynesians and Yanomami Indians. RESULTS: The ratio of the frequencies of the II, ID and DD genotypes were 1:2:1 in the Europeans, but there was a tendency towards a higher frequency of the D allele in the Nigerians. In contrast, the Samoans and the Yanomami Indians displayed a much higher frequency of the I allele than of the D allele. CONCLUSION: The relationship between ACE genotype and disease in these latter groups is still not known, but the present results clearly suggest that ethnic origin should be carefully considered in the increasing number of studies on the association between I/D ACE genotype and disease aetiology.

Absconders from the Nigerian National Neuropsychiatric Hospital: a case control study.

A case-control survey of 136 absconders who left hospital without permission on a total of 170 occasions over a 15-month period was carried out. Absconding tended to be more frequent during the day time shifts (in contrast to the night shifts) and during the weekdays (in contrast to the weekends). The destination in the majority (62.4%) was the home. Absconders differed significantly from non-absconders in terms of a tendency towards being single (p < 0.01), having a current or previous history of drug abuse (p < 0.01), being employed (p < 0.05) and staying longer on admission (p < 0.01). The results were discussed and explanations proffered for the significant differences. Finally, suggestions were made on ways of minimising the frequency of absconding from mental hospitals in the light of the results.

Nigerian secondary school teachers: a pilot survey of views and knowledge about drug abuse.

The views and knowledge level of 135 randomly selected Secondary School teachers in the Abeokuta Local Government area of Ogun State on drug abuse were sought through a self report anonymous questionnaire. They were mostly male teachers (59.3%) under the age of 30 years (89.6%). The majority (59.3%) were never exposed to drug education as students whilst less than 20% have been exposed since qualifying as teachers. 72.6% do not currently teach their students Drug education. Although the majority had a good concept of the definition of drug abuse, their view on the potential drugs of abuse and the concept of "drug dependence" were inadequate. Respondents recently exposed to drug education were more likely to identify salicylate analgesics as potential drugs of abuse at a statistically significantly level (p less than 0.05). 85.9% of the respondents chose "guidance counselling" as the approach to the management of student drug abusers despite the dearth of this professional cadre in the schools. The disquieting implications of these findings in relation to the National Campaign aimed at stemming the increasing tide of drug abuse among youths in the country were discussed and suggestions proffered on ways of rectifying these. Finally the authors gave suggestions on the pattern and content of teacher-targetted formal drug education programme in the light of the findings.

Human immunodeficiency virus genetic variation that can escape cytotoxic T cell recognition.

In a longitudinal study of HIV seropositive patients, there were fluctuations in the specificity of cytotoxic T cells for the virus. This was matched by variability in proviral gag DNA epitope sequences in the lymphocytes of these patients. Some of these viral variants are not recognized by autologous T cells. Accumulation of such mutations in T-cell antigenic targets would provide a mechanism for immune escape.

Pulmonary metastatic malignant tumours in Ibadan, Nigeria: 10 years autopsy review.

This study reports the findings of a ten year review of autopsy records at the University College Hospital, Ibadan, Nigeria of patients who died of malignant tumour metastases to the lungs and pleurae. During the study period 1977 to 1986, a total of 3,549 autopsies were performed out of which 339 cases 10.5 pc died of malignant tumours. One hundred and thirteen of these tumours (33.3 pc) metastasised to the lungs and pleurae among other sites. Further analysis of these 113 patients showed that 49 were male and 64 females giving a male:female ratio of 1:1,3. In addition, the ages of the patients ranged between 9 months and 90 years with a mean of 38.3 years. The uterus was the commonest organ from which pulmonary metastases occurred (28.3 pc), with choriocarcinoma being the predominant historical type of uterine tumour. The liver was the next most common organ 26.5 pc with male to female ration of 3:3,1. Twenty other organs were also identified, the breast, kidney and oesophagus 7 pc each; pancreas ovary and thyroid 3 pc each being the most important. Other organs are adrenals, foot, neck, cervix and rectum--2 pc each.

Nigerian juvenile offenders: a case-controlled study.

A case-controlled study was carried out on all the 51 juvenile delinquents found in a point prevalence survey of a Nigerian Borstal Remand Centre. Mean age of the delinquents was 17-27 years. They were mostly from the low social class (70.6%) and the commonest reason for admission was for being beyond parental control (68.6%). Identified risk factors found for juvenile delinquency were death of biological mother, parental marital failure, growing up with relatives rather than parents, drug abuse and ordinal position in the family. Possible cultural explanations for some of these observations were proffered. The need to improve on the living conditions of these juveniles and their assessment procedure were highlighted. Finally, it is imperative that the obsolete Nigerian Children and Young Person's Law be updated.

Intracellular sodium and blood pressure in Nigerians.

In examining the relationship between erythrocyte sodium, potassium, and blood pressure in Nigerians, we measured the erythrocyte sodium and potassium in 25 hypertensive and 34 normotensive subjects. Of the normotensive subjects, 15 had positive family histories of hypertension and 19 did not. The hypertensive subjects were older (50.1 +/- 1.7 years) than the normotensive subjects (25.4 +/- 0.7 years) (mean +/- SEM; P < .001). The mean arterial pressure in hypertensive subjects was higher (108.8 +/- 2.3 mm Hg), as expected, compared with normotensive subjects (86.98 +/- 1.62 mm Hg) (P < .001). The mean duration of hypertension in hypertensive subjects was 5.60 +/- 0.75 years. Erythrocyte sodium was higher in hypertensive subjects (9.57 +/- 0.19 mmol/L) compared with normotensive subjects (7.96 +/- 0.19 mmol/L) (P < .001). Among normotensive subjects, erythrocyte sodium was higher in those with a positive family history of hypertension (8.59 +/- 0.31 mmol/L) compared to those without such a history (7.47 +/- 0.18 mmol/L), and this was also statistically significant (P = .027). Erythrocyte potassium levels were similar in the hypertensive subjects (83.51 +/- 0.71 mmol/L), in normotensive subjects (81.86 +/- 0.81 mmol/L), and in those without a family history of hypertension (80.20 +/- 0.51 mmol/L) (P = .675). We observed a significant (P < .001) positive correlation between erythrocyte sodium and systolic (r = 0.99) and diastolic (r = 0.39) blood pressures. Our findings support the hypothesis that erythrocyte sodium is closely related to blood pressure and its nonracial genetic determinants.

Medical testimony in Nigerian courts

This paper focusses on medical testimony in Nigerian courts. It summarises the nature of the Nigerian legal process and how medical practitioners are expected to prepare for court appearance. Finally it discusses how they are to present their expert testimonies in court

Uraemia and adrenocortical function in Nigerian subjects.

In assessing the pituitary-adrenal axis of uraemic Nigerians, we investigated the circadian rhythm of plasma cortisol secretion, the response to the overnight dexamethasone (1 mg) suppression test and the pattern of excretion of urinary free cortisol (UFC) in 10 uraemic subjects and nine non-uraemic controls. Basal (0800 h) plasma cortisol levels were similar in both uraemic (mean +/- s.e.m.; 224 +/- 36 nmol/l) and non-uraemic (218 +/- 47 nmol/l) subjects. The non-uraemic subjects demonstrated the normal late night (2300 h) reduction in cortisol levels but this was absent in uraemic subjects in whom the basal and late night values were similar. Post-dexamethasone (0800 h) values were suppressed by 80% in non-uraemic subjects (P less than 0.01) from 218 +/- 47 nmol/l (at 2300 h) to 44 +/- 16 nmol/l (at 0800 h), whereas there was lack of suppression (P greater than 0.05) in values from uraemic subjects (224 +/- 36 nmol/l at 2300 h and 210 +/- 39 nmol/l at 0800 h). Irrespective of the degree of renal impairment in uraemic subjects, the 24 h UFC excretion was significantly greater (P less than 0.05) (1126 +/- 403 nmol/24 h) compared with non-uraemic subjects (342 +/- 94 nmol/24 h). These results confirm previous observations in Caucasians and reaffirm the existence of a pseudo-Cushingoid state in uraemia which may contribute to the associated hypertension and electrolyte abnormalities.

Psychiatric reports for Nigerian courts: an analysis of the views of the bench.

The views of magistrates and judges serving in Ogun State of Nigeria were assessed by means of an anonymous questionnaire. The latter sought such views on the psychiatric reports which they had previously received as well as what they considered useful information for inclusion in such reports. The response rate was 83%. The results suggest that psychiatric reports are thoroughly read by magistrates and judges and they are useful in the courts decision-making process. They viewed comments on "fitness to plead," "criminal responsibility" and "dangerousness" as quite useful information for the courts but these were at times missing in psychiatric reports. Also the majority were of the view that psychiatric reports were usually delayed, thus prolonging the trial of mentally abnormal offenders. The reason for this were cursorily highlighted and suggestions for speedier trials proffered. Finally, the authors provided a guide on information regarded as "useful" by these Nigerian courts and stressed the need for further investigation of the subject.