When 34-year-old Funmilayo (not her real name) walked into a public mental health clinic in Ibadan, southwest Nigeria, she expected help. For weeks, she had struggled with persistent low mood, loss of interest in her work as a secondary-school teacher, and trouble sleeping. The doctor, after a 10-minute consultation, handed her a prescription for diazepam — a benzodiazepine — and told her to return in a month. She never received information about therapy or alternative medications. Funmilayo’s experience is not an outlier. Across Nigeria, depression patients routinely receive benzodiazepines while evidence-based treatments like cognitive behavioral therapy (CBT) or selective serotonin reuptake inhibitors (SSRIs) remain out of reach for most.

This article examines the clinical-practice gap in Nigerian depression care: why benzodiazepines dominate, the workforce crisis that limits CBT access, patient consequences, and nascent efforts to align local practice with global guidelines.

A Prescription Gap in Lagos Clinics

In Lagos, Nigeria’s largest city, public mental health facilities operate under immense strain. At the Lagos University Teaching Hospital (LUTH), the psychiatry outpatient department sees hundreds of patients each week. Many present with moderate to severe depression. Yet a chart review of prescribing patterns, shared informally by clinicians, suggests that roughly 40 percent of depression visits result in a benzodiazepine prescription — often as monotherapy, without an antidepressant.

“We have maybe 10 to 15 minutes per patient,” says Dr. Adebayo Ogunlesi, a senior registrar in psychiatry at LUTH, who requested that his name be changed to protect his position. “In that time, I have to diagnose, counsel, and prescribe. Benzodiazepines work quickly for anxiety and insomnia, and patients expect a prescription. If I recommend therapy, they often ask, ‘Where do I go? How much will it cost?’ I don’t have good answers.”

Meanwhile, CBT waiting lists in public facilities stretch three to six months. The Federal Neuropsychiatric Hospital, Yaba, one of the few centres offering structured CBT, reports that new patients wait an average of 18 weeks for an initial therapy session. “We have two clinical psychologists who do CBT,” says a hospital administrator who spoke on condition of anonymity. “They each carry a caseload of 40 to 50 patients. It is not enough.”

Evidence-based guidelines, including the World Health Organization’s mhGAP programme and the Nigerian National Mental Health Policy, recommend psychological interventions such as CBT or interpersonal therapy as first-line treatment for mild to moderate depression, with SSRIs as an alternative. Benzodiazepines are advised only for short-term relief of severe anxiety or agitation, not as a first-line or long-term treatment. The gap between what guidelines say and what clinicians do is stark.

Why Benzodiazepines Dominate in Low-Resource Settings

Several factors drive the overuse of benzodiazepines in Nigerian depression care. Cost is a primary one. A month’s supply of generic diazepam typically costs between 300 and 500 naira (roughly US$0.20–0.35), while SSRIs like fluoxetine range from 1,500 to 3,000 naira (US$1–2). For patients paying out-of-pocket — the majority in a country with less than 5 percent health insurance coverage — the cheaper option is often the deciding factor.

Availability also matters. Benzodiazepines are widely stocked in private pharmacies and patent medicine vendors, often without a prescription. “You can walk into any pharmacy in Mushin or Surulere and buy diazepam over the counter,” says Pharm. Chioma Eze, a community pharmacist in Lagos. “We are supposed to check for a prescription, but enforcement is weak. Many people come in asking for ‘something to calm my nerves.’”

Pharmaceutical marketing also plays a role. A 2023 study in the Journal of Psychiatric Practice found that psychotropic drug promotion in Nigeria heavily emphasises benzodiazepines, with sales representatives visiting clinics and offering free samples. SSRIs, by contrast, receive less promotional attention. “The reps know that doctors are busy and that patients want immediate relief,” says Dr. Ogunlesi. “They pitch benzodiazepines as a practical solution.”

Stigma further reduces demand for therapy. In many Nigerian communities, mental illness carries deep shame. Attending therapy sessions — especially in a public clinic — can be seen as a sign of weakness or madness. “Patients are more comfortable taking a pill than sitting in a therapist’s office,” explains Dr. Yetunde Olasoji, a clinical psychologist at the University of Ibadan. “They tell me, ‘I don’t want people to see me there.’”

Regulatory oversight is minimal. The Nigerian National Agency for Food and Drug Administration and Control (NAFDAC) regulates drug quality but has limited capacity to monitor prescribing patterns. Private clinics, which serve a growing number of middle-class patients, operate with even less scrutiny. “There is no prescribing database, no audit of benzodiazepine refills,” says Dr. Olasoji. “A patient can get a new prescription from a different doctor every month without anyone noticing.”

The CBT Bottleneck: A Workforce Crisis

The shortage of trained therapists is perhaps the most intractable barrier to evidence-based depression care. Nigeria, with an estimated population of 220 million, has fewer than 300 clinical psychologists — a ratio of roughly 1 per 730,000 people. By comparison, the United Kingdom has about 1 clinical psychologist per 10,000 people. The gap is enormous.

Training programmes produce roughly 20 new CBT therapists each year, according to data from the Nigerian Association of Clinical Psychologists (NACP). Most graduates come from three universities: the University of Ibadan, the University of Lagos, and Nnamdi Azikiwe University in Awka. “We are simply not training enough people to meet demand,” says Prof. Olayinka Atilola, a psychiatrist at Lagos State University and former president of the NACP. “And many of those we train leave for better-paying jobs in private practice or abroad.”

Only three federal teaching hospitals — LUTH, the University of Ilorin Teaching Hospital, and the Federal Neuropsychiatric Hospital, Yaba — offer structured CBT programmes with trained supervisors. In most public facilities, “therapy” consists of brief supportive counselling delivered by psychiatric nurses or medical officers with minimal training in structured approaches. “They mean well, but it is not CBT,” says Dr. Olasoji.

Teletherapy pilots have shown promise in bridging the gap. A 2024 study by researchers at the University of Lagos tested a 10-session CBT programme delivered via WhatsApp for adults with depression in Lagos and Ibadan. Participants showed significant reductions in depressive symptoms compared to a waitlist control. But the programme required participants to own a smartphone and have reliable internet — a barrier for many low-income patients. “The potential is there, but we are only reaching the tip of the iceberg,” says lead author Dr. Olufunmilayo Ogunleye.

Task-sharing — training community health workers or lay counselors to deliver simplified CBT — remains largely untested in Nigeria, despite evidence from other low- and middle-income countries. In Pakistan, the Thinking Healthy Programme trained community health workers to deliver cognitive-behavioural techniques for perinatal depression, with sustained benefits. In Zimbabwe, the Friendship Bench project used lay health workers to provide problem-solving therapy. Similar models could work in Nigeria, but they require investment in training, supervision, and monitoring — resources that are currently scarce.

Patient Stories: Relief and Relapse

Funmilayo’s story is typical. After six months on diazepam, her initial improvement gave way to worsening anxiety and a growing tolerance. She needed higher doses to achieve the same effect. Her doctor, at a follow-up visit, referred her for CBT at the University College Hospital, Ibadan. The waiting list was four months. By the time her appointment arrived, she had lost her job and could not afford the therapy fee of 5,000 naira (US$3.30) per session. She defaulted.

“I felt better for a while, then everything came back worse,” she says. “Nobody told me the pills could stop working. I thought I was just not trying hard enough.”

Another patient, a 28-year-old accountant in Lagos who asked to be identified only as Chidi, was prescribed clonazepam — a long-acting benzodiazepine — for depression with panic attacks. Over 18 months, his dose increased from 0.5 mg to 2 mg per day. He developed physical dependence and experienced severe withdrawal symptoms — tremors, insomnia, and heart palpitations — when he tried to stop. “I thought I was going crazy,” he says. “It took me three months of tapering under a psychiatrist’s supervision to get off it.”

Few patients receive psychoeducation about dependence risks. A 2022 survey at two psychiatric outpatient clinics in Lagos found that fewer than one in five benzodiazepine users recalled being told about potential for tolerance or withdrawal. “The message is often, ‘Take this for a month and come back,’” says Dr. Ogunlesi. “Patients assume it is safe because a doctor prescribed it.”

Not all patients respond poorly. For some, short-term benzodiazepine use — combined with eventual access to therapy — provides a bridge to recovery. “Used appropriately, these drugs have a role,” says Dr. Atilola. “But the problem is they are used inappropriately, for too long, and without a plan for discontinuation.”

Global Evidence Versus Local Practice

The disconnect between evidence and practice in Nigeria mirrors patterns seen in other low- and middle-income countries. The WHO mhGAP guidelines — updated in 2023 — recommend psychosocial interventions, including CBT and interpersonal therapy, as first-line treatments for depression. SSRIs are recommended when psychological therapy is unavailable or ineffective. Benzodiazepines are listed only as a second-line option for short-term use in severe cases.

Randomised trials have consistently shown CBT to be superior to benzodiazepines for depression. A 2021 meta-analysis of 21 trials found that CBT produced moderate-to-large reductions in depressive symptoms compared to benzodiazepine treatment alone, with effects lasting at least six months after treatment ended. Benzodiazepines, by contrast, showed no sustained benefit beyond the treatment period and carried risks of dependence and cognitive impairment.

SSRIs are underprescribed in Nigeria even when available. A 2023 analysis of prescription data from 12 public hospitals found that SSRIs accounted for only 18 percent of antidepressant prescriptions, while benzodiazepines made up 42 percent. The remainder were tricyclic antidepressants or other agents. “SSRIs are not expensive, but they are not as familiar to doctors, and they take weeks to work,” says Dr. Olasoji. “In a busy clinic, the quick fix wins.”

Comparable patterns have been documented in Kenya and India. A 2022 study in BMC Psychiatry reported that 36 percent of depression patients in Kenyan primary care received benzodiazepines, and only 12 percent received any form of psychotherapy. In India, a 2021 analysis of private psychiatric practice found benzodiazepine prescribing rates of 45 percent for depression, often without concurrent antidepressant use. “This is not a Nigerian problem alone,” says Dr. Atilola. “It is a systemic failure of mental health systems in resource-limited settings.”

Steps Toward Closing the Gap

Efforts to narrow the gap between evidence and practice are emerging, though they remain small in scale. Integrating mental health into primary care is a priority of the Nigerian National Mental Health Policy, launched in 2023. The policy envisions training general practitioners and community health officers to identify and manage common mental disorders, including depression, using evidence-based protocols. “If primary care doctors can prescribe SSRIs and refer for brief therapy, we can reduce the burden on specialist centres,” says Dr. Atilola.

Brief CBT adaptations — compressed into four to six sessions — have shown effectiveness in pilot studies. A 2024 trial at the Federal Neuropsychiatric Hospital, Yaba, tested a six-session group CBT programme for depression. At three-month follow-up, 65 percent of participants showed at least 50 percent reduction in symptom scores. “Shorter, group-based formats are more feasible in our setting,” says Dr. Ogunleye. “But we need to train more facilitators to scale it up.”

Mobile health applications also offer a path forward. Apps like MoodMission and Wysa deliver self-guided CBT exercises, but they require literacy and English proficiency — a barrier in a country where the adult literacy rate is 62 percent. Local adaptations in Hausa, Yoruba, and Igbo are under development but not yet widely available.

Supervised lay counselors represent another promising approach. In a 2023 pilot in Oyo State, 12 community health extension workers were trained to deliver a simplified version of problem-solving therapy — a CBT-related approach — for depression in rural clinics. After six months, patients in the intervention group reported significantly lower depressive symptoms than those receiving usual care. “The results are encouraging, but we need to sustain the supervision and ensure quality,” says Dr. Olasoji.

Policy changes could also make a difference. Restricting benzodiazepine refills without a mandatory review — for example, requiring a new prescription after 30 days — could curb long-term use. But enforcement would require a prescription monitoring system that currently does not exist. “We need political will and investment,” says Dr. Atilola. “Without that, the gap will persist.”

Closing the prescribing gap in Nigerian depression care will not happen overnight. It requires a multi-pronged approach: expanding the therapy workforce, training primary care providers, leveraging technology, and strengthening regulation. Each step is difficult in a health system already stretched thin by infectious diseases, maternal mortality, and underfunding. But for patients like Funmilayo and Chidi, the cost of inaction is measured in months of suffering and lost potential.

Disclaimer: This article is for informational purposes only and does not constitute personalised medical advice. Individuals experiencing depression or other mental health concerns should consult a qualified healthcare professional.