Lagos, Nigeria — The first time Adeola’s son stopped sleeping, she thought it was exam stress. He was 24, finishing his degree in business administration. But the nights stretched into a week, then two. He began talking to himself, pacing the courtyard until dawn, convinced that neighbors were broadcasting his thoughts through the radio. A psychiatrist at the federal teaching hospital diagnosed schizophrenia and prescribed haloperidol decanoate injections every four weeks. For six months, the depot kept him stable. Then the hospital ran out.

Adeola, now 54, has watched her son relapse three times in two years. Each time, the pattern is the same: the pharmacy has no stock, she waits weeks for a new supply, and without the injection her son becomes agitated, stops eating, and eventually requires emergency hospitalization. “They tell me to come back next month,” she said in an interview. “But next month, there is nothing.” Her story is not unusual. Across Nigeria, patients with schizophrenia routinely go two to three months without long-acting injectable antipsychotics, a treatment that the best evidence suggests could halve their risk of relapse.

This gap between evidence and access is the subject of a growing body of research — and of quiet desperation among families who navigate a system where the most effective tool for severe mental illness is often the least available.

A Mother Watches Her Son Slip Away

Adeola’s son, whom we are calling Chidi to protect his privacy, was 28 when he received his diagnosis in 2022. His first hospitalization lasted three weeks. After discharge, he received his first depot injection at the hospital’s outpatient clinic. “He was like his old self again,” Adeola recalled. “He helped me with the shopping, he laughed with his cousins.” That lasted exactly two months. When she returned for the third injection, the nurse told her the haloperidol vials had not arrived from the central store. “Come back in two weeks,” she was told.

Two weeks became four. Adeola called the hospital each week. The answer was always the same: “No stock.” By week six, Chidi had stopped sleeping. He began shouting at passersby from the balcony. Adeola, frightened, bought oral haloperidol tablets from a street vendor, guessing at the dose. “I gave him one in the morning and one at night,” she said. “I didn’t know if it was too much or too little.” The tablets helped for a few days, but she could not afford the black-market price indefinitely — roughly 1,500 naira (about US$2) for a week’s supply, more than three times the official price.

By week ten, Chidi was hospitalized again. The hospital had received a new batch of depot vials, and he was restabilized. But Adeola knows the clock is ticking. “They say the medicine will last four weeks,” she said. “But when the hospital runs out, four weeks becomes four months.”

Why Nigeria’s Depot Antipsychotics Run Out

Nigeria’s National Essential Medicines List includes fluphenazine decanoate and haloperidol decanoate — both first-line long-acting injectables for schizophrenia. But listing a drug does not guarantee it reaches patients. Local pharmaceutical production covers less than 20% of the country’s demand for these formulations, according to industry estimates. The rest must be imported, and importers face chronic foreign-exchange shortages and port delays that can stretch months.

Public hospitals, which treat the majority of patients with severe mental illness, ration the vials they receive. “We have a list of patients who are considered priority — those with a history of multiple relapses or violent behavior,” a pharmacist at a Lagos teaching hospital explained, speaking on condition of anonymity because she was not authorized to comment. “Even they sometimes have to wait.” The rationing means that patients who are stable on depots are often shifted to oral medications, which are cheaper and more readily available but far less reliable for adherence.

Private pharmacies occasionally stock depot vials, but at prices three to five times the official rate. A single vial of haloperidol decanoate that costs roughly 2,000 naira at a public hospital can sell for 8,000 to 10,000 naira in private outlets — out of reach for most families. The result is a two-tier system: those who can afford private care get more consistent access; those who depend on public facilities cycle through relapse and hospitalization.

The Evidence for Long-Acting Injectables

The rationale for prioritizing depot antipsychotics is grounded in solid evidence. A Cochrane review of randomized trials found that depot haloperidol reduces relapse rates compared with oral haloperidol, with a number needed to treat of roughly four to six over one year — meaning that for every four to six patients treated with the depot formulation, one relapse is prevented. In high-income settings, adherence rates with long-acting injectables exceed 80%, compared with oral adherence rates that often fall below 50%.

In Nigeria, oral adherence is estimated below 40% at six months, according to a 2023 survey of patients at three psychiatric hospitals. The reasons are familiar: side effects, cost, lack of family support, and the stigma that makes patients reluctant to take daily pills in front of others. A depot injection, given every two to four weeks by a nurse, sidesteps many of these barriers. Modeling studies suggest that scaling up depot access could reduce rehospitalization rates by roughly half, freeing up scarce inpatient beds and saving families the financial and emotional toll of repeated crises.

But the evidence also comes with caveats. Depot formulations are not superior to orals for every patient; some people prefer pills and do well on them. The Cochrane analysis noted that effect sizes varied across settings, and that most trials were short-term. Still, for patients with a history of nonadherence — a majority in many low-resource settings — the case for depots is strong.

Survey Data Quantify the Access Gap

A 2024 study published by researchers at the University of Ibadan put numbers to what clinicians have long observed. Of 312 patients prescribed depot antipsychotics at three outpatient clinics, 62% had missed at least one scheduled dose in the preceding six months. The median gap between doses was eight weeks — two to four times the recommended interval. The most common reason patients gave was stockout at the dispensing clinic (44%), followed by cost (31%) and inability to travel to the clinic (18%).

Patients traveled an average of 35 kilometers to reach the nearest clinic that offered depot injections. For those in rural areas, the distance could exceed 60 kilometers. Public transport costs — roughly 500 to 1,000 naira round-trip — added to the burden. “I spend more on transport than on the medicine itself,” one patient in the study told researchers. The study did not track clinical outcomes of these gaps, but the authors noted that missed doses are a well-established predictor of relapse.

Other surveys paint a similar picture. A 2022 report from the Mental Health Foundation of Nigeria found that 58% of patients at primary care centers in Kaduna State had gone without depot injections for at least six weeks in the past year. The consistency of these numbers across regions suggests a systemic failure, not a local anomaly.

Innovations That Could Bridge the Gap

Several interventions could improve access to depot antipsychotics in Nigeria, and some are already being tested. The World Health Organization’s prequalification of generic paliperidone palmitate — a newer long-acting injectable that can be given monthly — opens the door for bulk procurement at lower prices. Nigeria’s National Mental Health Act of 2021 mandates the integration of mental health services into primary care, which could bring depot administration closer to patients.

Task-shifting is another promising approach. In pilot programs, nurses at local health centers have been trained to administer depot injections, reducing the need for patients to travel to specialist hospitals. A small study in Oyo State found that patients who received depots at primary care clinics had shorter gaps between doses than those who traveled to the teaching hospital. Digital tools, such as SMS appointment reminders, have shown modest success in improving adherence in a pilot in Lagos, though the effect was limited by phone ownership and network reliability.

Mobile pharmacy vans, used in some rural areas to deliver chronic disease medications, could be adapted for depot antipsychotics. A program in Kaduna State that combined mobile vans with nurse training reduced the proportion of patients who missed doses from 58% to 21% over six months, according to a 2023 program evaluation. The cost was roughly US$2 per patient per month — a fraction of the cost of a hospitalization.

Yet these innovations face obstacles. Task-shifting requires regulatory changes and sustained training funding. Mobile vans depend on fuel availability and road conditions, which are unreliable in many regions. SMS reminders assume patients have consistent access to mobile phones and network coverage — a challenge in rural areas where a substantial proportion of patients live. Without addressing these underlying barriers, even well-designed pilots may struggle to scale.

The Human Cost of Interrupted Treatment

The consequences of depot stockouts extend beyond relapse. Each hospitalization for acute psychosis costs a family an estimated 50,000 to 100,000 naira (roughly US$60 to US$120) in direct medical expenses, plus lost income from caregiving. For a family earning 30,000 naira a month, a single hospitalization can push them into debt. Adeola sold her sewing machine to pay for Chidi’s second admission. “I had used it to make clothes for neighbors,” she said. “Now I have nothing to sell.”

The social toll is equally severe. Neighbors who once greeted Chidi now cross the street when they see him. His younger siblings have stopped bringing friends home. “They are ashamed,” Adeola said quietly. “They don’t say it, but I know.” The stigma of mental illness in Nigeria is profound; families often hide a relative’s diagnosis for fear of being ostracized. When a patient relapses publicly — shouting, wandering, disheveled — the shame deepens, and the family’s social network contracts.

Children with schizophrenia face particular vulnerabilities. A 2023 case series from Lagos University Teaching Hospital described three adolescents who dropped out of school after depot stockouts led to relapses. One 16-year-old girl, stabilized on fluphenazine decanoate for two years, missed three consecutive doses when her clinic ran out. She was hospitalized for six weeks and has not returned to school. “She was at the top of her class,” her mother told the researchers. “Now she can barely read a sentence.” The long-term developmental impact of such interruptions is not well studied, but clinicians worry that repeated relapses during adolescence may worsen the course of the illness.

Trade-Offs and Competing Priorities

Some health economists argue that prioritizing depots over other interventions may not be the most efficient use of Nigeria’s limited mental health budget. Oral risperidone, for example, costs roughly 500 naira per month at public hospitals and is widely available. A 2021 cost-effectiveness analysis from the University of Ibadan found that while depots reduced relapse more effectively, the incremental cost per relapse averted was high — roughly 150,000 naira — when factoring in the price of the injectable and the logistics of cold-chain storage. The authors concluded that for patients with good oral adherence, orals may be more cost-effective.

But oral adherence in Nigeria is poor, as noted. The same analysis found that among patients with a history of nonadherence, depots were dominant — both more effective and less costly, because they prevented expensive hospitalizations. The question, then, is not whether depots work, but how to target them to the patients who need them most. In practice, this triage is rarely done. “We give depots to whoever we have vials for,” the Lagos pharmacist said. “There is no formal system to prioritize.”

Another trade-off involves newer versus older depots. Paliperidone palmitate, a second-generation injectable, has a side-effect profile that may be more tolerable than haloperidol’s — less risk of movement disorders — but it costs roughly 5,000 naira per dose at private hospitals, compared with 2,000 naira for haloperidol. Bulk procurement through the WHO could narrow this gap, but Nigeria has not yet applied for the prequalified generics. Meanwhile, some clinicians worry that focusing on paliperidone could divert attention from fixing the supply chain for cheaper, older drugs that still work for many patients.

What Patients and Families Do Now

In the absence of reliable public supply, families improvise. Some pool money to buy depot vials from private hospitals, sharing the cost among relatives. Others switch to oral olanzapine, which is cheaper and more widely available but carries risks of significant weight gain and metabolic side effects. A few turn to traditional healers, who may offer prayers or herbal remedies when medicines run out. “I have nothing against the traditional healer,” Adeola said. “But I know the injection is what keeps my son well.”

Support groups have emerged as an informal safety net. On WhatsApp, groups of families share stockout alerts — “No haloperidol at LUTH this week” — and coordinate to buy from private suppliers when a batch becomes available. Advocacy organizations, such as the Mental Health Foundation of Nigeria, petition state health ministries quarterly, presenting data on missed doses and requesting emergency supplies. Progress is slow. “We get promises, sometimes a small allocation, but the problem never goes away,” said the group’s director.

The cycle takes a toll on families. Adeola has stopped working to care for her son. Her other children send money from abroad, but it is never enough. “I am tired,” she said. “But what can I do? He is my son.”

A Modest Fix With Measurable Impact

The solutions are not expensive or technologically complex. A dedicated depot supply chain — separate from the general pharmaceutical pipeline — could cost roughly US$2 to US$4 per patient per month, according to estimates from the World Bank’s mental health program. Training 500 nurses to administer depots at primary care centers would cover an estimated 80% of the current unmet need, based on population modeling by Nigerian researchers.

Pilot projects have shown that these interventions work. In Kaduna State, the combination of mobile vans and nurse training reduced the proportion of patients who missed doses from 58% to 21% within six months. The cost was modest, and the effect was sustained at 12-month follow-up. Scaling such programs nationally would require political will and coordination between federal and state health ministries — not new drugs or large infrastructure investments.

But political will is in short supply. Mental health receives less than 5% of Nigeria’s health budget, and most of that goes to psychiatric hospitals in urban centers. The National Mental Health Act, passed in 2021, has not been fully implemented; regulations for primary care integration are still being drafted. For families like Adeola’s, the wait continues. “If they could just keep the medicine in stock,” she said, “my son could stay at home.” A reliable depot supply would not cure schizophrenia, but it would give patients and families something almost as valuable: predictability in a disease defined by uncertainty.

This article is for informational purposes only and does not constitute medical advice. Individuals with mental health conditions should consult a qualified health professional for diagnosis and treatment.