Mental health service provision is one of the significant global health issues gaining attention with nearly 90% of untreated cases of mental health conditions residing in low- and middle-income countries (LMICs) where 80% of people have been reported to battle with one case of mental health or the other [1]. Evidence from the World Mental Health Surveys suggested that in Nigeria, less than 1% of persons with anxiety disorders and 6% of those with mood disorders made any treatment contact in the year of the illness [2]. The majority of Nigerians who sought treatment did so in primary or general healthcare settings where the service provision is nearly unavailable [3, 4].

Recognizing this critical gap, the World Health Organization (WHO) launched the Mental Health Gap Action Programme (mhGAP) in 2008 [5]. This initiative strives to expand and improve mental health services in LMICs. A key component of mhGAP is the mhGAP Intervention Guide (IG), released in 2010 [6]. The IG aims to integrate mental health care into primary care and community settings by equipping non-specialist healthcare providers with the necessary tools, training, and support to deliver evidence-based interventions. The focus is on priority mental, neurological, and substance use (MNS) disorders as defined by the WHO for LMICs.

The mhGAP-IG has been adopted in over 100 countries, including Nigeria, and has demonstrated effectiveness in delivering evidence-based mental health services (MHS) within primary healthcare systems in resource-constrained settings [7]. The core objective is to enhance the capacity of non-specialists in the identification, treatment, and management of MNS conditions through a model of stepped care and collaborative task-sharing. The mhGAP-IG covers a range of modules, including introductory material, essential care practices, and specific guidance on conditions such as depression, psychosis/mania, epilepsy, child and adolescent mental health, dementia, substance use disorders, self-harm/suicide, and other significant mental health complaints. While mhGAP doesn’t have dedicated anti-stigma modules, it emphasizes the importance of using non-stigmatizing language, demonstrating empathy, and promoting community awareness about mental illness. Evidence suggests that mhGAP training itself can contribute to reducing stigma among trainees.

Family physicians, as primary care physicians (PCP) are crucial in providing effective healthcare at first contact. Beyond offering comprehensive and continuous care for various health issues, they must also be equipped to facilitate timely referrals to specialized care when necessary. While mhGAP-IG implementation has been evaluated in numerous contexts, a comprehensive review of 162 studies by Keynejad and colleagues highlighted the need for further research on its implementation [8]. Therefore, this study aimed to investigate the awareness and engagement of family physicians in implementing mental health interventions within the framework of the mhGAP. The study also sought to identify factors that either facilitate or impede their involvement, contributing to a better understanding of how to bridge the mental health action gap.

1.1 Awareness levels of mhGAP in Nigeria

Mental health awareness in Nigeria is a growing concern, with a significant gap between the demand for mental health services and the available resources. Research has shown that primary care workers in Nigeria lack the necessary training and support to provide adequate mental health care [3]. The Mental Health Gap Action Programme (mhGAP) has been implemented in Nigeria to address this gap. The programme provides training for primary care workers on mental health care, with a focus on community-based care. Physicians in Nigeria are involved in mhGAP, primarily through training and capacity building, clinical supervision and mentorship, program evaluation and monitoring, policy development and advocacy, and community engagement and awareness [9].

Family physicians’ awareness levels of the mhGAP in Nigeria are crucial for effective mental health care delivery. Physicians’ awareness levels of the Mental Health Gap Action Programme (mhGAP) in Nigeria vary. A study done in Nigeria to assess knowledge and attitude towards mental health among primary health care workers reported that knowledge of PHC workers about psychopharmacology was low. Most of them reported negative attitudes towards mental illness [10].

1.2 Factors influencing awareness

Training and education: Research has shown that primary care workers in Nigeria lack the necessary training and support to provide adequate mental health care [3, 11]. Physicians who received training on the mhGAP were more likely to be aware of the programme [3]. A study found that primary care workers need further training to manage the mental health needs of their patients. This study also identified a need for peer support and supervision from experienced clinicians [12]. An overall 25% improvement in knowledge about MNS disorders following mhGAP-IG training in Iraq shows the effectiveness of training and education [13]. Hughes et al. also reported that in-person training of 52 participants, 25 of whom were primary care physicians, with country-specific and needs-led mhGAP-IG training, showed an 8.5% improvement in post-training test scores [14].

Professional experience: More experienced physicians were more likely to be aware of the mhGAP [8].

Access to resources: The key strategy for increasing awareness is providing training programmes for primary care physicians on mhGAP-IG, with a focus on community-based care. This will help inform PCP on mhGAP and thus increase their involvement and implementation of its use. Physicians with access to the internet and other resources were more likely to be aware of the mhGAP [6]. Reiss et al. found that participants improved their knowledge and skills from training on the mhGAP online course [15].

1.3 Physicians’ involvement levels in the implementation of the mental health gap action plan

Physicians’ involvement in the Mental Health Gap Action Programme (mhGAP) in Nigeria is crucial for effective mental health care delivery. The involvement levels of physicians in the mental health action gap in Nigeria are a pressing concern. This gap is further exacerbated by the limited availability of mental health professionals, particularly in rural areas.

Inadequate training of primary care providers, which results in poor mental health condition recognition and treatment, lack of support and supervision for their work, an uncoordinated referral pathway through the various health service tiers, and policy neglect—which frequently takes the form of inadequate funding, irregular medication supply for MNS conditions, and weak health systems—are the reasons for this gap [14, 15]. Additionally, Wakida et al. identified the following barriers: (a) a lack of mental health care in-service training, combined with no formal discussions about mental health disorders with higher-level supervisors; (b) a lack of coordination between mental health specialists and general health workers; and (c) a lack of support from the district medical team [16]. The majority of healthcare providers 236 (58.7%) in Ethiopia had stated that there was a poor implementation level of mental health integration [17]. The experience from other Sub-Sahara Africa (SSA) countries has also raised concerns about challenges of integration such as poor policy implementation, insufficient numbers of mental health professionals to drive and support the process, poor community engagement and mobilization, and the non-availability of medications [18].

1.4 Innovative ways of integration of MHS into PHC care (Key Physicians’ Involvement Levels)

To bridge this gap, it is essential to increase awareness and education about mental health issues in Nigeria. This can be achieved through community-based initiatives, public awareness campaigns, and training programs for primary care workers.

1.4.1 Mental Health Gap Action Programme (mhGAP) training and supervision

This program provides competency-based training for primary care workers, focusing on mental health care. The mhGAP-IG and a carefully monitored cascade-training methodology make it possible to expand mental health services in Nigerian primary care settings. This teaching approach is practical, economical, and promising, particularly in environments with a shortage of experts [3]. Primary care workers require more comprehensive training and ongoing support to effectively address mental health issues with the use of WHO guidance in MHS treatment support. Physicians should act as Master Trainers, providing training and supervision to non-physician primary care workers. A pilot project in Osun State, Nigeria demonstrated the feasibility of scaling up mental health services through a cascade training model, where Master Trainers trained Facilitators, who then trained primary care workers [3]. The following obstacles were noted: (a) insufficient mental health care in-service training, in addition to the absence of formal conversations regarding mental health disorders with higher-level supervisors; (b) insufficient coordination between mental health specialists and general health workers; and (c) insufficient assistance from the district medical team [16].

1.4.2 Clinical support

Mental illness is often stigmatized, leading to delayed or inadequate treatment [2]. Physicians should offer clinical support to patients and guidance to primary care workers, ensuring conformity to the mhGAP-IG and ease of referral to mental health specialists. Mental health facilities and resources are scarce, particularly in rural areas. Limited resources for mental health treatment provision (eg medicines and staff) in remote areas like Edawu, can create challenges in implementing mhGAP treatment plans in the long run [18, 19]. Hence, the a need for physicians to be more involved in the implementation of mhGAP-IG and to maximize the use of the available scarce resources. Encouraging peer learning and support among primary care workers can help bridge the mental health action gap.

1.4.3 Monitoring and evaluation

The purpose of the monitoring exercise was to encourage integrity in the application of the mhGAP standards and to reinforce skills learned during training. To determine the training program’s efficacy and pinpoint areas for development, doctors should take part in monitoring and evaluation activities. The monitoring activities may include: (1) going over clinical notes to make sure that all clinical encounters are properly documented; (2) having a supervisor observe the health providers’ clinical assessment of patients using the mhGAP-IG in a non-intrusive manner, and (3) holding debriefing meetings with the clinical staff to go over the observations or notes made in (1) and (2) [3]. Evaluations can be carried out in an organized manner and include comprehensive details regarding patient flow, clinical documentation, fidelity, and the referral process.

1.4.4 Digital solutions

Leveraging digital platforms and telemedicine can increase access to mental health services, particularly in rural areas [20].