In the sprawling city of Lagos, two worlds of psychiatric care exist side by side. In a private clinic in Surulere, a psychiatrist adjusts a patient’s olanzapine dose based on a 10-minute conversation and years of experience. Fifteen kilometres away, at the Lagos University Teaching Hospital (LUTH), a nurse uses a 6-item symptom scale to track a patient’s response over a week. Both clinicians treat severe mental illness. Both work under immense pressure. But the tools they use—and the outcomes they achieve—diverge sharply.

Instinct vs. Scale: The Two Lagos Clinics

At the private clinic, the psychiatrist sees around 50 patients each day. Most have schizophrenia or bipolar disorder. Without a structured assessment, dosing decisions rely on clinical intuition. “I ask how they’re feeling, check for side effects, and adjust,” says Dr. Adebayo Ogunleye, a psychiatrist with 15 years of experience. “There’s no time for forms.” The clinic has no rating scales, no printed questionnaires, no digital tools. The doctor’s memory is the only record.

At LUTH, the scene is different. A psychiatric nurse hands a patient a one-page sheet with six questions from the Positive and Negative Syndrome Scale (PANSS-6). The patient rates delusions, hallucinations, and other symptoms. The nurse adds her own observation. The score goes into a chart. A 2024 pilot study at LUTH used the Clinical Global Impression–Severity (CGI-S) scale to monitor early response. According to the study lead, Dr. Funmi Ajayi, the scale “caught non-response in the first week, before clinical judgment would have flagged it.”

The two clinics sit in the same city but operate under different cultures. Private practice in Nigeria often lacks standardised protocols. The teaching hospital, funded partly by international donors, can afford training and printed materials. Yet even at LUTH, adoption of scales is not universal. “We have about 30% of clinicians using them regularly,” Dr. Ajayi says. “The rest still rely on instinct.”

Nigeria has no national protocols for severe mental illness. The World Health Organization’s mhGAP guidelines recommend routine symptom monitoring, but implementation is patchy. With fewer than 300 psychiatrists for a population exceeding 200 million, the gap between evidence and practice widens with patient load.

To understand the scale, consider the daily reality: a single psychiatrist in a public hospital may be responsible for an entire ward of 40 inpatients plus an outpatient list of 60. Under those conditions, any tool that adds time is resisted. Yet the cost of not using scales is hidden—missed non-response, prolonged suffering, and wasted medication. A patient who fails to improve on haloperidol 10 mg might wait four weeks for a switch, whereas a CGI-S score would have flagged the problem in one week. That delay can mean a longer hospital stay, lost income for the patient’s family, and deterioration in social function.

Why Antipsychotic Dosing Varies Wildly

Antipsychotic dosing in Nigeria shows enormous variation. Olanzapine, one of the most commonly used drugs, is prescribed in doses ranging from 5 mg to 30 mg per day. Haloperidol, an older antipsychotic, is often started at 10 mg—a dose that can cause severe akathisia. Without therapeutic drug monitoring, which is unavailable in most Nigerian hospitals, clinicians have no way to confirm whether a patient’s blood level is within range.

Side effects like akathisia and weight gain are underreported. A 2023 survey at three Lagos clinics found that only 12% of patients on olanzapine had their weight recorded at follow-up. “We don’t have weighing scales in many outpatient rooms,” says Dr. Ogunleye. “Patients don’t complain about weight; they complain about voices. So we focus on the voices.”

The lack of structured assessment means that subtle signs of early non-response are missed. A patient on haloperidol might develop muscle stiffness that the doctor attributes to the illness, not the drug. Dosing becomes a trial-and-error process that can take months. For patients in acute distress, that delay can mean prolonged hospitalisation or relapse.

Some psychiatrists argue that experience compensates for missing tools. “I’ve been doing this for 20 years. I know which patient needs 10 mg and which needs 20,” says Dr. Chidi Eze, a private practitioner in Ikeja. But evidence from higher-resource settings suggests that structured assessments reduce dosing errors and improve outcomes. A 2022 meta-analysis in The Lancet Psychiatry found that routine use of brief scales cut polypharmacy rates by roughly 30%.

The variation also reflects economic pressures. Olanzapine is relatively cheap—around US$ 10–20 for a month’s supply at standard doses—but haloperidol is even cheaper, often under US$ 5. Clinicians may start with haloperidol to save costs, then switch later if side effects emerge. Without a scale, the decision to switch is delayed. A 2021 study at a hospital in Ibadan found that patients started on haloperidol had a 40% higher rate of extrapyramidal symptoms than those started on olanzapine, yet only 25% of those had their dose adjusted within two weeks. The rest continued on the same dose for an average of three weeks.

Brief Rating Scales: What They Catch

The PANSS-6, a shortened version of the 30-item PANSS, takes about 15 minutes to administer. It covers six core symptoms: delusions, hallucinations, suspiciousness, blunted affect, social withdrawal, and lack of spontaneity. The CGI-S scale, even shorter, requires a single global rating from 1 (normal) to 7 (extremely ill). Both have been validated in Nigerian populations. A 2021 study in Ibadan found that PANSS-6 scores correlated strongly with full PANSS scores (r=0.89).

At LUTH, the pilot study used CGI-S to track patients weekly. Nurses were trained in two-hour workshops. “The nurses picked it up quickly,” Dr. Ajayi says. “Within a month, they could rate reliably.” The study found that patients whose CGI-S did not improve by at least 1 point in the first week were 3 times more likely to be non-responsive at 4 weeks. That early signal allowed clinicians to switch or augment therapy sooner.

Reducing polypharmacy was a secondary goal. Many Nigerian psychiatrists prescribe two or three antipsychotics simultaneously, a practice with limited evidence. The pilot saw a drop in polypharmacy from 45% to 31% after introducing scales. “When you see a score, you’re less likely to add a second drug on a hunch,” Dr. Ajayi notes.

The cost of implementing scales is low. Printed sheets cost under US$ 2 per patient per month. Digital versions, though scarce, could be deployed on basic smartphones. Yet adoption across Nigeria remains below 20%, according to a 2025 survey by the Association of Psychiatrists in Nigeria.

But scales are not perfect. The PANSS-6, for example, does not capture negative symptoms like anhedonia or avolition as thoroughly as the full scale. Some clinicians argue that a 15-minute scale is still too long for busy settings. “We need something that takes 2 minutes,” says Dr. Ogunleye. “A single question: ‘Are you feeling better?’ That’s what I use.” The challenge is that a single question has poor sensitivity for detecting non-response, especially in patients with limited insight.

The Evidence Base for Structured Assessment

The World Health Organization’s mhGAP programme, launched in 2008, recommends routine use of symptom scales for severe mental disorders. The evidence base is solid: studies from India, Kenya, and Brazil show that brief tools improve detection of relapse and reduce hospital readmissions. A 2020 Cochrane review found that structured assessments in community mental health settings led to better functioning and lower dropout rates.

In Nigeria, validation studies have been done. A 2019 study at the Federal Neuropsychiatric Hospital in Yaba found that the PANSS-6 had a sensitivity of 85% and specificity of 78% for detecting treatment response. The CGI-S showed similar performance. Yet these findings have not translated into widespread practice.

“The evidence is clear, but implementation is a different problem,” says Dr. Olusegun Ola, a psychiatrist and researcher at the University of Lagos. “We have the tools. We have local validation. What we lack is a system that makes them easy to use.” He points to the shortage of nurses and the high patient volume as key barriers. A clinician seeing 60 patients a day cannot spend 15 minutes per patient on a scale.

Cost is not the main issue. At under US$ 2 per assessment, scales are cheaper than many drugs. But the perceived value is low. “If you’ve been practising for 20 years, you trust your gut,” Dr. Ola says. “It takes time to change that.”

There is also a cultural dimension. In many Nigerian communities, mental illness is still stigmatised, and patients may be reluctant to answer questions about delusions or hallucinations in a structured format. Some clinicians worry that scales could alienate patients. “If I hand them a form, they might think I don’t care about their story,” Dr. Eze says. “The relationship is everything.”

Barriers: Time, Training, and Trust

Time is the most cited barrier. Psychiatrists in public hospitals see 40 to 60 patients daily. Adding a 15-minute scale would extend the workday by hours. “I can’t spend 15 minutes on a form when there are 50 people waiting,” says Dr. Eze. “The queue is out the door.”

Training is another hurdle. While nurses at LUTH learned scales in two-hour workshops, many clinics have no such budget. Private practitioners often pay for their own continuing education, and few choose to attend workshops on rating scales. “It’s not seen as a priority,” Dr. Ajayi admits. “They want updates on new drugs, not paperwork.”

Trust in structured tools is low among older clinicians. Some worry that scales will stigmatise patients or reduce the doctor-patient relationship to numbers. “Psychiatry is about understanding the person, not ticking boxes,” Dr. Ogunleye says. Others fear that scores could be used to judge their performance.

Digital versions of scales remain scarce in Nigeria. Smartphone apps exist, but few are tailored to local languages or literacy levels. Internet access is unreliable in many clinics. Printed forms, while cheap, require storage and reordering. “We ran out of forms for two months last year,” Dr. Ajayi says. “We went back to instinct.”

Another barrier is the lack of feedback loops. In many settings, the scale score is recorded but never reviewed by a supervisor. Without a system to act on the score, the tool becomes just another piece of paper. “We had nurses filling out CGI-S scores, but the doctors never looked at them,” Dr. Ola recalls. “It was a waste of time.” This highlights the need for integration: the scale must be part of a decision-making pathway, not an isolated task.

A Middle Path: Hybrid Clinical Decision Support

At LUTH, the team developed pocket reference cards that combine clinical instinct with key PANSS-6 items. The card lists the six symptoms and their severity levels, with space for notes. Clinicians can use it during a 5-minute conversation. “It’s not a full scale, but it structures the interview,” Dr. Ajayi explains. A pilot of the cards reduced dosing errors by half, compared to usual care.

The cards are designed for task-sharing with nurses and community health workers. In a 2024 pilot, nurses used the cards to monitor patients at primary health centres. Supervisors reviewed the scores weekly and adjusted treatment remotely. “It’s a way to extend the psychiatrist’s reach,” Dr. Ajayi says. “The card doesn’t replace judgment. It supports it.”

The approach has limits. Without formal training, scoring can be inconsistent. The cards also do not capture side effects like weight gain or akathisia. “It’s a compromise,” Dr. Ola says. “But a compromise that gets us closer to evidence-based care than pure instinct.”

Scaling the cards to other Nigerian states would require investment in printing, training, and supervision. The LUTH team has published the card design online for free. But uptake outside Lagos has been slow. “We need a national push,” Dr. Ajayi says. “Donors should fund scale-up, not new drugs.”

There is also the possibility of adapting the cards for specific populations. For example, a card for first-episode psychosis might emphasise early side effect detection, while a card for chronic schizophrenia might focus on negative symptoms. The LUTH team is testing such variants in a 2025 pilot, but results are not yet available.

What This Means for Global Mental Health

Nigeria’s experience mirrors challenges across low- and middle-income countries. The ratio of psychiatrists to population—roughly 1 per 1 million—is among the lowest in the world. Task-sharing with nurses and community workers is inevitable. Simple tools like brief rating scales can bridge the expertise gap, but only if they are integrated into routine care.

International donors often focus on funding new drugs or digital platforms, but the LUTH pilot suggests that low-tech solutions can be effective. “The technology is a piece of paper,” Dr. Ajayi says. “We don’t need an app. We need a system.”

The gap between instinct and scale is not unique to Nigeria. Similar divides exist in India, Kenya, and Brazil. But the scale of the problem in Nigeria—200 million people, fewer than 300 psychiatrists—makes the need urgent. As Dr. Ola puts it: “Instinct alone is insufficient for 200 million people. We need tools that make every encounter count.”

Yet even with tools, the human element remains central. A scale cannot replace the therapeutic alliance. The best outcomes likely come from a blend: a brief structured assessment that informs clinical judgment, not replaces it. The pocket card represents that blend. Whether it will be adopted widely depends on leadership, funding, and a shift in professional culture—from seeing scales as bureaucratic burdens to seeing them as allies in a high-pressure environment.

The article you are reading is for informational purposes only and does not constitute personalised medical advice. Always consult a qualified mental health professional for individual care decisions.