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Mental illness is a major world epidemic. Yet one unlikely nation seems immune.
"What makes Nigerians so extraordinarily resilient?"
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According to the World Bank, the average Nigerian earns $300 a year and has a life expectancy of 45.3 years. Nearly six percent of the young female population there has HIV, only 7.1 in a thousand has a computer, electricity and other services are luxuries, and the country is drowning in $31.1 billion of debt. Yet, apparently, the Nigerians are onto something. In 2003, a World Values Survey of more then 65 countries ranked Nigeria number one in terms of happiness. That finding, apparently, was no fluke. In June 2004, a major World Health Organization survey of 14 countries and two Chinese cities found those impoverished but exuberant Nigerians putting the affluent but angst-ridden Americans and Europeans to shame with a 12-month prevalence of mood disorders of 0.8 percent, far less than any of the surveyed nations. The US had the dubious distinction of leading the pack at 9.6, while Shanghai clocked in at 1.7, Beijing 2.5, Japan 3.1 and the European nations ranged from 3.6 for Germany to 9.1 for the Ukraine.
The WHO Survey was led by Ronald Kessler PhD of Harvard, who was the principal investigator of the ground-breaking US National Comorbidity Survey of 1991-1992 and its follow-ups, as well as the director of various other WHO population studies. Nigeria was the only African nation surveyed. The two Latin American nations in the study and Lebanon had far more in common with the European nations than with either Nigeria or the Asian populations. Other survey findings documented Americans out in front by a wide margin in anxiety disorders (at 18.2 percent compared to the second place French at 12 percent) and number two in substance use (3.8 percent compared to 6.4 percent for the Ukrainians).
In all, 26.4 percent of Americans had a mental illness over the past 12 months - 7.7 in the serious category and 9.4 percent moderate - outpacing second place Ukraine by nearly six points. The one-third serious mental illness to total mental illness ratio held steady across all nations. Other European totals ranged from 8.2 percent Italy to 18.4 percent France. Japan finished at 8.8 and Nigeria and Shanghai brought up the rear at 4.7 and 4.3, respectively.
Those with serious disorders reported that they were unable to carry out their usual activities for about 30 days owing to their illness. The predictable exception was Nigeria at 15.2 days. US residents spent 66.9 days under the covers and Italians kept the lights out for 206.4 days.
The survey did not offer any reasons for why Americans and Europeans are so depressingly ill, but it will undoubtedly spur researchers to look for smoking guns. Based on earlier cross-national population data, Joseph Hibbeln MD of the NIH in two studies found that people in countries that consumed a lot of fish (such as Japan) experienced less depression and bipolar disorder. Similarly, Arthur Westover MD of the University of Texas Southwestern Medical Center discovered that sweet tooth populations (such as the US) coincided with higher rates of depression.
An obvious research priority is finding out what makes the Nigerians so extraordinarily resilient in the first place. Call it Factor X, the why things work effect. First we need to determine if the WHO investigators got this part of the study right. Then, should the figures check out, we should send in the troops - geneticists, physicians, epidemiologists, sociologists, psychologists, anthropologists, environmental scientists ... quantum physicists if it’s even remotely relevant.
At the same time, we need to look at the problem from the other end - namely why we have a mental illness epidemic in the west despite access to reasonably effective treatment. Call it Factor Q, the why things fail effect. Granted, so-called access can be a cruel joke. The survey found that only about half of those with serious mental illness in western countries are being treated, and a third and a quarter respectively for moderate and mild illness. Still, shouldn’t we be hearing that the experts have the situation under control?
Solving these riddles shouldn’t be impossible. Between the failings of the successful nations and the apparent success of a failing one lies the dream of every visionary in the field - a new mental health paradigm, the answers to Factors X and Q. Excelsior.
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June 13, 2004
Deb (June 14, 2004): I have been diagnosed with Bipolar by 2 doctors, Schizoaffective by a therapist, Artistic by a Psychiatrist. Yet I work full time, have a family, volunteer, and am on the honors role at my university. If I have a mental illness and I can do this, give me more!!
Anna (July 23, 2004): What do the Nigerians have that we
McMan (July 23): Amen to that, Anna.
Pearl 10/14: Nigerians probably have very different values to us in the West. Perhaps when you are so busy trying to get your basic survival needs met, I don't think you\'d survive if you had a mental illness! I would also go over the survey results again just to check if they understood the questions....
Jeanne (Dec 5, 2004):What don't Nigerians have that we do? A diet of highly processed foods. Umm...maybe a connection?
McMan (Dec 5): Amen again.
Diana (Dec 8, 2004): Look at the countries less immune to depression, developing and poor. I'm not so sure its such a mystery. Look at the definition of depression, these people are trying just to make it from day to day. For instance, decrease in appetite is one marker of depression, in US you may be depressed if you chose not to eat. Plus we are talking about a totally different culture with different values ideas and norms. Hard to imagine that DSM4 is not the universal bible. Really come on look at the criteria for ex. borderline personality disorder, over 200 different combinations to meet the criteria in U.S. Depression is not a text book definition in some countries, it's probably a luxury for some.
Dr Rob (Jan 19, 2005): Everyone's entitled to my opinion, so here it is--my opinion on why the WHO finds Nigeria such a mentally healthy place. It also has little or no Alzheimer\s disease (B Osuntokun).
The key to understanding most mental illness (anxiety, depression, bipolar. schizophrenia) is the landmark discovery that fatty maternal diet in pregnancy--especially late pregnancy, during rapid foetal brain growth--is the direct root cause of Chronic Anxiety Disorder (let's call it CAD).
This discovery was made by myself, and it took me 5 years to do it (1990-1995). I research Essential Fatty Acids (both families of "EFA"--Omega-6 and Omega-3). The fatty Western diet is high in saturated and trans-fatty acids, and low in EFA, especially the Omega-3 family. This diet creates EFA-deficient cell membranes, causing chronic oxidation, inflammation and insulin resistance, resulting in diabetes, heart and vascular disease, and cancers of breast, bowel and prostate--the typical degenerative diseases rarely or never seen in traditional societies.
It also causes anxiety and depression, but a calm person eating fatty diet does not get depressed--merely tired and overweight. To get depressed--and I repeat, this is a major discovery--the evidence points to a fatty maternal diet in pregnancy, as the original cause of CAD in the offspring; and if the latter partake of a similar fatty diet (eg. in adolescence), then they will become depressed. Simple as that.
Here's the evidence:-
1) Fatty diet causes gestational diabetes (R Moses, L Tapsell, 1994), as well as adult diabetes in general (H Himsworth, Clinical Science, 1936).
2) Gestational diabetic pregnancies produce children with cognitive and behavioral disorders, the latter being shyness and introversion (B Silverman, Chicago, 1993). I have checked and confirmed in hundreds of anxious patients, that the mother's diet was in fact rather fatty in pregnancy--usually butter and cream, or a lot of cheese, but also beef dripping, lard, bakery shortening, or cheap margarines rich in trans-fats.
Anxious folks--about 20-30% of people in Western nations--do not get depressed if their own diet is healthy and low-fat, which seems to be the case in about half of all anxious folk. They may even feel less anxious--if eating corn, whole grains and legumes, which provide a natural cure for CAD (Inositol--see below).
But about half of all anxious folk do eat fatty diet--often driven by comfort-eating of sweet fatty foods--and they get depressed as a result, due to oxidation and reduced energy production in the brain. Treatment with Fish oil fatty acids sometimes helps this depression, by improving the cell membrane level of EFA--but stress itself responds poorly.
The correct treatment of stress is Inositol, either from its food sources, or from the powder supplement (5-10 gm daily). I use a "comprehensive regimen" of healthy diet, Inositol and Fish oil, in all my anxious, depressed, bipolar and schizophrenic patients in general family practice. The results are comprehensive! I rarely have to use any medical drug for these disorders.
Another cause of depression--especially in the young--may be refined polyunsaturated vegetable oils, which lose 30% of their vitamin E during steam-deodorization. These anti-oxidant deficient oils are the direct cause of Alzheimer's disease (Peers R, 1993, New Zealand Med J. 106:481), but when consumed in pregnancy they also cause Attention Deficit Hyperactivity Disorder, quite a different disorder (unpublished case-control study).
Children with ADHD are now seen all over the world, because refined food oils are now consumed so widely in pregnancy. Such children develop depression and conduct disorder if they consume such oils themselves, due to lipid peroxidation in the brain. Although the ADHD may largely settle by age 12 or so, many cases have persisting problems with depression, antisocial behaviour, inattention and impulsivity, and concentration, in adult life. IQ, strangely, is preserved, unlike in many anxious people.
Furthermore, refined oils can precipitate "youth depression" in congenitally anxious cases from "fatty" pregnancies, and I suspect that anxious folks using refined oils get more depressed than cases of adult ADHD. Thus, refined oils may explain the earlier onset of major depression in recent years, because the addition of dietary fat (not oils) to anxiety used to result in a delayed mid-life depression in the mid-20th century, the onset being between 45 and 50 years (West, 1955).
All of which means that if we look at the pregnancy diets in different countries, we will be able to solve the challenging problem of rising depression rates, by explaining why some countries, like Nigeria, get so little depression. Any psychiatrist will tell you that under depression, one usually finds an anxious person, and my research offers a plausible pre-natal reason for that anxiety.
So in Nigeria, we expect to see a low-fat diet in pregnancy, and in fact their main dietary fatty acids there are EFA, from fish and peanut meal. A WHO study on schizophrenia (Christophersen, 1988) found low rates and much better recovery in poor, but low-fat, nations including Nigeria.
In contrast, congenital stress (CAD) is a frequent component part of the worse schizophrenia outcomes documented in high-fat nations like Denmark. Furthermore, even when CAD cases do occur in poorer societies (eg, from ghee consumption in Indian pregnancies), the diet of those countries often includes Inositol-rich whole grains, corn and legumes, which would automatically improve such anxiety and assist recovery from depression or psychosis.
The dreadful figures on depression in the US, parts of Europe and even the Middle East, probably reflect the anxious aftermath of fatty diets in pregnancy, aggravated by current fatty diet (or refined oils) in the depressed person. The high (19%) lifetime rate for depression in Beirut may reflect the widespread use of semi-solidified synthetic ghee in the Arab countries: Saudi women, for example, have high rates of post-natal depression, while bad nerves and stress are common in Iran, where beef dripping is very popular in cooking. I stress that it is the use of these unhealthy fats in pregnancy, that explains later depression, by causing permanent stress in the offspring.
Low depression rates are typical of Oriental peoples, as in Taiwan and Okinawa, where the diet is rich in seafood and low in fat. However, some pig fat and fatty coconut cream are used by pregnant women in parts of China and South-East Asia, and ghee is found in India and Pakistan, all of which means chronic stress for the offspring. The aboriginal Hos people of Bihar province in India eat no fats or oils at all, since they only boil their food; I wonder if they have no depression or anxiety at all!
The answer to all this depression is obvious--governments must devise national nutrition programmes to educate and indoctrinate the masses on healthy diet. Fatty diets must be discouraged, and a tax put on fatty foods. Good EFA intake must be assured, from fish, micro-encapsulated fish oil food supplements, nuts, avocadoes, eggs, and food oils with corrected vitamin E content. Inositol powder supplement must be mass-produced and subsidized, to treat existing anxiety disorders. Consumption of whole-grain, high fibre diet will supply further Inositol, and may replace the supplement in mild cases of anxiety. Inositol also has anti-cancer, anti-diabetic and anti-ageing properties.
A comprehensive regimen--my Triple Treat of Diet, Inositol and Fish oil!--will deal with most mental health challenges, without any need for expensive and ineffective pschiatric drugs--not just depression, and the anxiety underlying it, but also the chronic co-morbid stress so often seen in the two psychoses (bipolar disorder and schizophrenia, which both respond to fishoil as well).
A new world awaits us, thanks to Nutrition and the Science of Prevention.
PS. The correction of low vitamin E levels in steam-refined food oils (by "topping up") would eliminate both Alzheimer's disease and ADHD, and would also get rid of the aggravating effects of refined oils on anxiety and depression. Existing cases of Alzheimer's and ADHD can be treated with vitamin E and fish oil, with the addition of Inositol in the 50% or so of Alzheimer cases who have a history of anxiety.
Renee 2/15: Dr. Rob, I don't dispute your opinion that the American fat-rich diet could cause the effects mentioned and many more. I am concerned that anyone would think that a government mandate is the answer. Education is certainly called for and asking our government to help educate is reasonable, but financial punishment is out of line. Neither you nor our government has a responsibility or right to mandate what any other person chooses to put in their body
Sunil 5/21: They know the value of life on earth . they r enjoying every moment of life ..
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