Soc Psychiatry Psychiatr Epidemiol (2001) 36: 8693

Steinkopff-Verlag 2001

ORIGINAL PAPER
J. U. Ohaeri

Caregiver burden and psychotic patients' perception

of social support in a Nigerian setting

Accepted: 13 November 2000

j Abstract Background: In Nigeria, there are no

national social welfare and community rehabilitation
programmes for the mentally ill. Families have to bear
the major burden of care. The present study aimed to
assess the severity of indices of burden among relatives
of 75 schizophrenics and 20 major affective disorder
cases, to identify the factors associated with burden, to
assess the relationship between caregiver burden and
patients' perception of social support, and to compare
these with equivalent data for cancer patients' relatives.
Method: Caregivers were assessed, using a burden
questionnaire and Goldberg's General Health Questionnaire (GHQ-12). Patients were assessed for perception of social support from the extended family.
Results: Clinical severity and burden indices were
similar for the psychiatric illness groups. However,
relatives of patients with psychotic symptoms, uncooperative behaviour, marital instability and unemployment had signicantly higher GHQ scores; while
patients from such families perceived a wider social
support network. Financial burden was greater than
effect on family routines. Disruption of family routines,
GHQ scores and (inversely) size of family network
patient expected support from, predicted global rating
of burden. Although clinical severity and disruption of
family routines for cancer patients were higher;
relatives of psychiatric patients had higher GHQ scores,
more family disharmony and greater social stigma.
J. U. Ohaeri1
Department of Psychiatry,
College of Medicine,
University of Ibadan,
Ibadan, Nigeria

Introduction
In Western countries, the involvement of families in
the care of severe mentally ill relatives grew from the
late 1950s, with the movement towards deinstitutionalization, consequent on the introduction of effective
antipsychotic drugs (van Wijngaarden et al. 2000).
However, the success of the industrial social welfare
state in these countries has resulted in numerous
nancial and other supports for the patients, such as
sheltered housing and employment, welfare payments
and subsidized cost of treatment. It is estimated that
25% of discharged chronically mentally ill patients
return home to their families in these countries
(Talbot 1984; Rose 1996).
In Nigeria and most developing countries, there
are no national social welfare programmes, medical
insurance schemes, or community-based rehabilitation programmes. Hence, all discharged patients are
expected to return to their families. The family has to
bear the burden of chronic mental illnesses, without
assistance from the state. It is this social scene that
has contributed to the differences in cost of mental
disorders between developed and developing nations.
In a study of the nancial cost of schizophrenia in
Nigeria by our group, it was found that antipsychotic
drugs accounted for 52.8% of the (direct and indirect)
cost of illness (Sulaiman et al. 1997). In most reports
from the Western world, before the wide use of novel

SPPE 430

Present address:
1
Department of Psychiatry, Psychological Medicine Hospital,
Gamal Abdel Naser Road, Sabah Area,
P.O. Box 4081, Safat, Kuwait, 13041
e-mail: judeohaeri@hotmail.com
Fax/Tel.: +965-4899315

Conclusions: Disturbed behaviour is a greater determinant of severity of burden than psychiatric diagnosis;
hence adequacy of treatment is a rst step in reducing
caregiver burden. The tolerance shown by this group
of relatives implies that they have strong potentials for
playing useful roles in community care. Research
and policy should consider measures to strengthen
extended family network ties in developing countries.

87

`atypical' antipsychotics, drugs constituted 25% of

the total cost of schizophrenia (Davies and Drummond 1994). In another Nigerian study of schizophrenics it was found that, although the greatest
burden was scored for effect on family routines, rural
families experienced signicantly greater nancial
burden than those living in urban areas (MartynsYellowe 1992). In line with the ndings from developed countries that the psychosocial burden of
schizophrenia is higher than that of some severe
physical illnesses (Andrews et al. 1985), Ige (1993)
compared the relatives of 50 schizophrenics, 47
asthmatics and 46 epileptics attending a Nigerian
hospital, and reported that the families of schizophrenics experienced the greatest burden.
Although most studies of family burden of mental
illness have focused on schizophrenia (Loukissa 1995;
Rose 1996), researchers that included affective disorder cases have noted that the degree of burden
reported by caregivers did not differ signicantly
across psychiatric diagnostic groups (Jenkins and
Schumacher 1999; Perlick et al. 1999). There is robust
evidence that caregivers' experience of burden is
related to specic illness symptoms and abnormal
behaviour, rather than to a psychiatric diagnosis per
se (Schene et al. 1998; Ricard et al. 1999). There is a
paucity of studies investigating the relation of caregiver burden with social support, especially the
patients' perception of social support from the
extended family, and it would be helpful to know
whether the patients' afrmation of support is related
to caregiver burden (Rose 1996). Towards this end,
Biegel et al. (1994) found that, in a sample of 103
family caregivers, lower amounts of perceived support
from family members signicantly predicted higher
levels of global caregiver burden. Also in a 1-year
follow-up study of 159 relatives of schizophrenics,
Magliano et al. (2000) arrived at the same conclusion.
The present study sought to extend previous
Nigerian works on caregiver burden in the following
ways:
1. Comparing schizophrenia with major affective disorder cases thus examining the effects of psychiatric
diagnosis on caregiver burden
2. Including patients at different levels of illness severity/ recovery thus examining the effects of psychiatric symptoms and behaviour
3. Assessing the relationship of caregiver burden with
patients' perception of psychosocial support from the
extended family thus examining how the patients'
afrmation of support is related to caregiver burden,
and
4. Comparing these aspects of caregiver burden with the
burden of relatives of cancer patients thus situating
the burden of severe mental disorders in the context
of a most severe physical illness.

The aims of the study were to assess the severity of

indices of psychosocial and economic burden among
rst-degree relatives of 75 schizophrenics and 20
major affective disorder cases, and to identify the
factors associated with global rating of burden and the
relationship of burden with the patients' perception of
social support from the extended family. The results
are compared with the ndings of a recent similar
study of relatives of cancer patients in the same
hospital (Ohaeri et al. 1999), and discussed in the
light of similar studies from abroad.

Subjects and methods

j Burden questionnaire
The operational denition of ``burden'' followed that articulated by
Platt (1985) for psychiatric patients, namely: the presence of
problems, difculties or adverse events which affect the lives of
patients' signicant others. In particular, ``burden'' was taken to
refer to that element of hardship explicitly attributed to the patient
(Gibbons et al. 1984). Using these principles from psychiatric
researchers (Hoening and Hamilton 1966; Platt 1985; Schene et al.
1998), our group had articulated and successfully eld-tested a
Nigerian culture-relevant caregiver burden questionnaire for cancer
patients. This could easily be adapted for studying other chronic
medical illness groups, by inserting the appropriate disease name
(Ohaeri et al. 1999). The contents of the questionnaire were guided
by the domains of burden highlighted by Platt (1985) and Hoening
and Hamilton (1966) for psychiatric patients. Based on our
experience of psychosocial problems of chronic mental illnesses in
the country (Ohaeri et al. 1995a; Sulaiman et al. 1997), the
questionnaire was accordingly modied for the present study.
Items of the questionnaire sought to elicit responses on severity of
``objective'' and ``subjective'' burden (Hoening and Hamilton 1966).
Under objective burden, we recorded a broad range of adverse
effects on the family, such as nancial loss; impairment of work
efciency; disruption of routine family activities (e.g. household
work); disruption of family interactions (e.g. emotional climate at
home) and physical health. Under subjective burden, we recorded
what the relatives felt about the illness, and the general feeling of
difculty they experienced in caring for the patient (details of the
questionnaire are available from the author on request).
Two typical items to elicit responses on key domains of objective
burden are as follows:
1. Has the patient lost any sort of revenue or nancial benets
(e.g. loss of job, loss of working hours for business or going to farm
or going to sell at the market, etc.)? Response options were: No
such losses/Minor loss of revenue or benets/Moderate loss of
income/Major loss of income, which has greatly affected the family.
2. Has taking care of the patient caused a neglect of the attention
that should be given to other members of the family (e.g. spouse
leaving children at home in order to stay in hospital with the
patient or take patient to other places of care, etc.)? Response
options were: Not at all/Occasionally so/Frequently so/All the time.
The items on objective burden, therefore, involved four response
options with increasing severity as above (i.e. score of 03). This
section consisted of 12 items.
Two typical items to elicit responses on subjective burden are as
follows:
1. Does the family feel embarrassed that so many people have to
know that the patient has this sickness? Response options were:
Not at all/Occasionally so/Regularly so/It was so initially, but we
have overcome that feeling now.

88
2. On the whole, how much difculty do you have coping with this
patient's condition? Response options were: None at all/Mild
difculty/Moderate difculty/Severe difculty.

operation with clinic attendance and compliance with follow-up

medication at home were also assessed.

This section of the questionnaire consisted of eight items.

Disease severity was quantied by collecting information on
frequency of hospital attendance and hospital admissions in the
past 12 months, frequency of psychotic symptoms in the past 3
months (Ricard et al. 1999) and how frequently the patient is taken
to sleep at church for prayers, and to the traditional (native)
healer's for treatment (Famuyiwa and Asuni 1991).
The last part of the questionnaire consisted of the 12-item version
of Goldberg's (1972) General Health Questionnaire (GHQ-12). The
GHQ is a screening instrument to delineate probable psychiatric
caseness. It has been used by our group in previous hospital and
community-based studies (Ohaeri and Odejide 1993, 1994).

j Procedure

j Questionnaire for patients' perception of social support

from the extended family
In a recent study, we highlighted the perception of schizophrenic
and major affective disorder patients of the categories of relatives
whom they regarded as family members beyond the categories of
spouse and children and the types of support they had received
from these members in the past year (Ohaeri 1998). First, the
questionnaire assessed the number of categories of relatives
constituting the extended family network (e.g. uncles, rst cousins,
etc), thus dening the size of extended family network for each
patient. Then the questionnaire assessed the size of family network
for the following domains of support:
1. Those in whom the patient tended to conde to solve problems
related to the illness;
2. Those from whom the patient expected support
3. Those from whom the patient actually received material and
emotional support, and
4. Those who regularly interacted with the patient in the past 3
months.
Summary scores were generated and used for correlation analysis
with indices of caregiver burden. The validity and reliability of that
questionnaire have been presented (Ohaeri, available from the
author on request). Only 41 patients were interviewed with this
questionnaire. We have already reported on the highly signicant
reliability indices of the burden questionnaire when used for
relatives of cancer patients (Ohaeri et al. 1999). The validity of this
slightly modied version for relatives of psychiatric patients was
tested by being presented for comments to senior psychiatrists and
nurses in the specialty. They all made complimentary comments on
the questionnaire. The questionnaires were all translated into the
local Yoruba (also the language of interviewer) by the method of
back translation.
j The psychiatric patients
The patients fullled ICD-10 (World Health Organization 1992)
criteria for diagnosis of one of the severe mental disorders, namely,
schizophrenia, bipolar disorder with psychotic symptoms and
recurrent severe depression. In order to have patients with
reasonable stability of psychiatric diagnosis and sufcient experience of the illness and its burdens, those included needed to have
had at least 2 years' duration of illness, and to have regularly
attended our hospital for follow-up care during that time, as shown
by their case notes (Ohaeri et al. 1995a; Jenkins and Schumacher
1999). In order to dene categories of well being, patients at three
levels of severity of illness/recovery were recruited, viz: (1)
inpatients; (2) outpatients with stable psychotic symptoms, not
requiring hospitalization; (3) outpatients with no psychotic symptoms, attending clinic for routine follow-up. The patient's co-

The study involved interview of rst-degree relatives who accompanied consecutive patients to the psychiatric clinic of the
University College Hospital (UCH), Ibadan, Nigeria, for treatment.
Relatives of patients in a stable condition were interviewed at the
clinic, while those of patients requiring admission were interviewed
2 days later at the ward, after completion of admission formalities.
To be included in the study, the patient had to be accompanied to
hospital by adult relatives who were directly involved in informal
care giving roles at home (either living with the patient or seeing
the patient regularly). In Nigerian culture, it is quite common for
patients to be accompanied to hospital by relatives (Ohaeri 1998).
Also, as is usual in this culture for this type of study, all the patients
and relatives who were approached consented to be interviewed.
Each subject was interviewed privately. All the interviews were
conducted by a senior female research nurse, who had also
interviewed the relatives for the earlier study of cancer patients and
their relatives. She was trained in the use of the questionnaire by
the author. Data collection commenced when the researcher was
satised that she had achieved high competence in reading out the
items of the questionnaire in Yoruba (the local language), and
rating the responses. In consideration of the relatively low literacy
rate in our country, and in order to make for uniformity, all the
subjects had the items of the questionnaire read out to them, and
the research nurse rated their responses.
j Data analysis
Data were analysed by SPSS computer package, using frequency
counts and chi-square tests (with Yates' correction, where necessary)
for categorical variables. Continuous variables were analysed by
means and t-tests, one-way analysis of variance (with Tukey's
method of multiple comparison), Pearson's correlation, and multiple
regression analysis, at a 5% level of statistical signicance. Caregivers
of patients with schizophrenia were compared with those of patients
with affective disorders. Caregiver burden indices were analysed
with regard to differences in patients' levels of illness/recovery, cooperation with clinic attendance and perception of social support
from the extended family network. Multiple regression analysis was
used to delineate factors that could predict felt subjective burden,
using the global item of how much difculty the caregiver
experienced in caring for the patient as dependent variable.
The summary burden score for each domain of objective burden
(e.g. nancial) was derived by adding up the scores on the relevant
items. As these domains did not contain equal numbers of items,
raw scores were weighted by dividing the total scores by the
number of items. The severity of the patient's clinical condition was
quantied as earlier highlighted, and operationally dened as
``clinical severity burden''. Hence the following burden summary
scores were obtained:
1. Clinical severity burden score: a measure of clinical severity of
the illness
2. Financial burden score: a measure of family's nancial distress
3. The weighted nancial burden score was then computed by
dividing the nancial burden score by ve (i.e. number of items
assessing nancial burden)
4. The family routine burden score, a measure of disruption of
family routines (e.g. difculty in keeping to household work),
was derived by adding up the score on four related items
5. The family disharmony score, a measure of the level of cordial
relationships at home and with neighbours (e.g. quarrels,
feelings of isolation by neighbours) was derived by adding up
the score on three related items

89
6. The weighted family burden score was derived by adding up the
routine burden score and disharmony score, and dividing by
seven.

Results
j Socio-demographic characteristics of psychiatric
patients and their caregivers (Table 1)
Mothers constituted the most frequent category of
caregivers (n 35; 36.8%), and most caregivers
(81%) lived with the patients. There were no significant gender differences (except that female patients
were more likely to be married). Most caregivers
(64.2%) were gainfully employed as junior civil
servants (21.1%) or senior professionals/private businesses (43.1%). Most patients (86.3%) lived with rstdegree relatives, who were typically married (66.3%).

gender differences in clinical characteristics. In the

past 3 months, 46 patients (48.4%) had experienced
psychotic symptoms several times weekly/daily; but
the majority (n 59; 62.1%) had not been hospitalized in the past year.
There were no signicant differences between the
schizophrenic and major affective disorder cases for
age of patients (36.8, SD 13.5 vs 38.1, SD 14.5;
P > 0.05); duration (years) of illness (9.9, SD 7.4 vs
8.05, SD 6.6; P > 0.05); weeks of symptoms in the past
3 months (3.9, SD 2.7 vs 3.08, SD 2.2); or age of
caregivers (45.6, SD 16.2 vs 51.5, SD 16.6; P > 0.05).
There were 19 inpatients (20%) and 55 outpatients
(57.9%) with stable psychotic symptoms, and 21
outpatients (22.1%) without psychotic symptoms.
Summary scores of burden (Table 2) for the two
illness groups and gender showed no signicant
differences.

j Clinical characteristics

j Severity of psychiatric caregiver burden

(Tables 2 and 3)

Signicantly more females (33.3% of 42) than males

(11.3% of 53) had affective disorders (v2 6.8,
df 1, P 0.009). There were no other signicant

The summary scores of clinical severity for the

inpatients (6.3, SD 1.5) and outpatients with psychotic
symptoms (6.1, SD 1.5) were signicantly higher than

Table 1 Characteristics of psychiatric

patients and caregivers

Variables
Patient characteristics
Age
Mean (SD)
Range
1530 yrs: n (%)
3140 yrs: n (%)
>65 yrs: n (%)
Occupation
Unemployed/farmer/petty trader: n (%)
Junior worker/school teacher: n (%)
Level of education
No formal/primary school: n (%)
Secondary school: n (%)
Marital status
Married: n (%)
Caregivers' characteristics
Mean age (SD)
Occupation
Unemployed/farmer/petty trader: n (%)
Junior worker/school teacher: n (%)
Level of education
No formal/primary school: n (%)
Secondary school: n (%)
Marital status
Married: n (%)
Living arrangements
Patient lives with parent/spouse/sibling
Caregiver lives with patient
Caregiver's relationship with patient
Parent/spouse/sibling
How long caring for patient (yrs): mean (SD)

Men
(n = 53)

Women
(n = 42)

t
(v2)

df

P-value

34.8 (12.8)
1574
24 (45.2)
18 (33.9)
3 (5.6)

39.8 (14.3)
1675
12 (28.6)
13 (30.9)
5 (11.9)

1.8

93

0.08

27 (50.9)
6 (11.3)

19 (45.2)
5 (11.9)

4.2

0.24

15 (28.3)
15 (32.1)

12 (28.6)
14 (33.3)

0.39

0.9

12 (22.6)

26 (61.9)

46.7 (16.7)

47.3 (15.6)

0.2

93

0.9

17 (32.1)
12 (22.6)

17 (40.5)
8 (19.0)

0.73

0.7

20 (37.7)
15 (28.3)

19 (45.2)
9 (21.4)

1.4

0.7

35 (66.6)

28 (66.7)

45 (84.9)
42 (79.2)

37 (90.0)
35 (83.3)

44 (83.0)
7.3 (5.7)

33 (78.6)
9.5 (7.0)

1.6

93

0.7

90
Table 2 Comparison of mean (SD)
summary scores of caregiver indices
of clinical severity and other burdens
between schizophrenia and affective
disorders (GHQ-12 12-item General
Health Questionnaire)

Burden indices

All
(n = 95)

Schizophr.
(n = 75)

Aff. Dis.
(n = 20)

P-value

1.
2.
3.
4.
5.
6.
7.
8.

5.9 (1.6)
11.0 (4.5)
2.2 (0.9)a,b
7.5 (2.8)
4.5 (2.0)
1.7 (0.5)a
1.8 (0.6)b
1.9 (2.6)

6.1 (1.5)
11.2 (4.5)
2.2 (0.9)
7.6 (3.0)
4.4 (2.0)
1.7 (0.6)
1.9 (0.7)
1.9 (2.6)

5.4 (1.7)
10.5 (4.4)
2.1 (0.9)
7.2 (2.0)
4.9 (1.9)
1.7 (0.5)
1.7 (0.5)
2.2 (2.9)

1.7
1.1
1.1
0.6
0.9
0.1
0.4
0.4

0.09
0.5
0.5
0.5
0.4
0.9
0.5
0.7

Clinical severity
Financial burden
Weighted financial burden
Family routine burden
Family disharmony score
Weighted family routine burden
Weighted subjective burden
GHQ-12 score

a,b
Weighted financial burden was significantly higher than weighted family routine burden score (t = 4.6, P = 0.0001) and
weighted subjective burden (t = 3.36, P = 0.008)

Table 3 Frequency of indices of clinical severity and psychosocial burden in 95

caregiver relatives of patients with schizophrenia or affective disorder, presented as absolute numbers (n) with percentages in parentheses
Indices

n = 95

1. Moderate/major loss of revenue by patient because ill

2. Moderate/major loss of revenue by family member
on patient care
3. Expenditure incurred has moderate/major impact
on family
4. Family taken moderate/major loan/sold property
5. Patient frequently/cannot attend work/school
6. Patient frequently has difficulty with household work
7. Patient's illness frequently disrupted caregiver's work
8. Frequently caring caused neglect of other family members
9. Caring never caused quarrel or disagreement at home
10. Family does not feel secluded/isolated/stigmatised
11. Global rating of family difficulty with coping
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty

58 (61.1)
36 (37.9)
53 (55.8)
22 (23.2)
34 (35.8)
30 (31.6)
11 (11.6)
9 (9.5)
56 (58.9)
73 (76.8)
16
21
37
21

(16.8)
(22.1)
(38.9)
(22.1)

those for outpatients without psychotic symptoms

(4.8, SD 1.5) (F 5.8, df 2/90, P 0.004). The
mean GHQ-12 scores (i.e. mental distress) for caregivers of inpatients (3.29, SD 3.2) and sick outpatients
(2.0, SD 2.65) were signicantly higher than those of
outpatients without psychotic symptoms (0.7, SD
1.38) (F 4.9, df 2/90, P 0.009). Also, relatives of
patients who did not cooperate to attend clinic had
higher GHQ-12 scores (3.2, SD 2.9) than relatives of
patients who readily cooperated in attending the
clinic (1.6, SD 2.4) (t 4.9, P 0.027). However,
there were no signicant group differences in summary scores for nancial burden, disruption of family
routines and family disharmony scores (P > 0.05).
For the entire cohort, the highest burden was nancial
(Table 2). When the data on psychiatric patients'
perceptions of support were analyzed with respect to
their clinical status, it was found that the perceived
material support network of inpatients and outpatients with psychotic symptoms (5.0, SD 1.4 and 5.4,
SD 2.1, respectively) were rated almost signicantly
higher than those of outpatients without psychotic

symptoms (3.7, SD 1.9) (F 3.02, P 0.06). Also, the

patients with symptoms tended to perceive a wider
social support network (6.0 and 5.5, respectively) than
the outpatients without symptoms (4.2, SD 1.6)
(F 2.5, P 0.09). In addition, patients who did
not cooperate to attend clinic perceived a wider
regular interaction network (3.3, SD 1.5) than patients
who cooperated in attending clinic (1.9, SD 1.1)
(t 4.4, P 0.04). Table 3 shows that, although 60
caregivers (61%) admitted moderate/severe global
rating of difculty in caring for the patient, the
majority of families lived peacefully (58.9%) and did
not feel socially stigmatized (76.8%).

j Factors associated with burden

among psychiatric caregivers (Table 4)
One-way analysis of variance (ANOVA) was used to
compare differences in summary burden scores
across marital, occupational and educational groups.
The only signicant differences were as follows:
1. Caregivers of patients who were separated/
divorced, experienced signicantly higher family
routine burden (F 4.6, P 0.01) and nancial
distress (F 4.6, P 0.01) than did caregivers of
patients who were married.
2. Caregivers who were unemployed experienced
signicantly higher nancial burden (F 6.1, P
0.003), subjective burden (F 3.35, P 0.039) and
GHQ-12 scores (F 7.5, P 0.001). Also, global
rating of difculty with caring for the patient was
signicantly more frequently rated as severe when the
patient was separated/divorced than when the patient
was either single or married. Table 4 shows that,
using the summary scores in Pearson's correlation
analysis, global rating of difculty with caring for the
patient was signicantly directly correlated with
objective and subjective burden indices (P 0.001),
GHQ-12 scores (P 0.015), and inversely correlated
with the patient's perception of extended family
support (P 0.015). Caregiver GHQ-12 scores were
signicantly correlated with family nancial distress.

91
Table 4 Factors associated with burden among 95 caregiver to psychiatric
patients: correlation coefficients (r) (t) and P-values
Factors/variables

P-value

Relation between global rating of difficulty by caregiver and:

Family financial distress
0.48 3.47
Disruption of family routines
0.43 3.04
Weighted family burden score
0.48 3.51
Weighted subjective burden
0.32 2.15
Caregiver's GHQ-12 score
0.39 2.77
Patient's expectation of support from network )0.37 2.48
Patient's occasional interaction network
)0.34 2.17

0.001
0.005
0.001
0.04
0.015
0.015
0.04

Relation between caregiver perception of clinical severity and:

Duration of illness
0.35 2.37
GHQ-12 score of caregiver
0.32 2.18

0.02
0.04

Relation between Caregiver GHQ-12 score and:

Family financial distress

0.04

0.31

2.12

In view of these multiple relationships, the data were

subjected to multivariate statistics. In multiple regression analysis including burden indices and demographic and clinical variables, global rating of
burden was signicantly predicted only by weighted
family burden score (t 3.1, P 0.003) and GHQ-12
score (t 2.4, P 0.02); and these accounted for 59%
of the variance. Of the indices of patient's perception
of family support, only the index on expectation of
support from extended family signicantly (inversely)
predicted global rating of family burden (t )2.4,
P 0.02), accounting for 37% of the variance. That is,
the greater the patient's expectation of support from
the extended family network, the less the global
feeling of burden by the caregiver.
Compared with the results of a similar study of
caregivers of patients with cancer in the same hospital
(Ohaeri et al. 1999), we found that, although the
summary score on disease clinical severity was much
higher for cancer (7.6, SD 1.8, vs 5.9, SD 1.6 for this
study), the two groups of caregivers had similar
weighted nancial burden scores (2.1, SD 0.9 for
cancer, vs 2.2, SD 0.9) and weighted family burden
scores (1.9, SD 0.5 for cancer, vs 1.8, SD 0.6). However,
caregivers of psychiatric patients had a higher mean
GHQ-12 score (especially relatives of affective disorder
cases: mean 2.2, SD 2.9) than cancer caregivers (1.3, SD
1.9). Although a higher proportion of cancer caregivers (83.4% of 73) than psychiatric caregivers (61%)
rated global difculty with caring as moderate/severe,
and more cancer caregivers (68.4% vs 55.8%) had
incurred signicant nancial costs, a signicantly
higher proportion of psychiatric caregivers admitted
that caring for the patient had caused quarrels at home
(41% for psychiatric vs 4% for cancer) and social
stigma (23.2% for psychiatric vs 1.4% for cancer).
Accordingly, the family disharmony score for psychiatric caregivers (4.5, SD 2.0) was appreciably higher
than that for cancer caregivers (3.4, SD 1.2).

Discussion
The ndings are not generalizable, since the subjects
were not a representative sample of the general
population. However, the socio-demographic and
clinical characteristics of the patients were similar to
those of previous studies of psychotic patients in our
locality (Ohaeri 1993; Ohaeri et al. 1995b). Another
limitation of the study is the fact that only one
caregiver was interviewed per family. Following the
example of previous workers, we tried to make up for
this, rst by interviewing those most closely involved
in care giving roles (Jenkins and Schumacher 1999;
Perlick et al. 1999), and second, by the attempt to
correlate patient's account with caregiver burden. In a
comparative study of key relatives and other relatives
of patients with schizophrenia, the levels of burden
and risk of developing psychiatric symptoms were not
signicantly different in the two family groups
(Magliano et al. 1999). However, there is evidence to
suggest that families of psychiatric patients experience
impaired family functioning (Miller et al. 1986; Keitner et al. 1987). In line with this view, the mean GHQ12 score of the caregivers in this study (1.9, SD 1.6) was
at least twice as high as that of civil servants (0.81, SD
1.6) who were involved in a recent general population
study in the locality (Ohaeri and Sunmola 1994).
It is reasonable to expect that, being a terminal
illness, cancer would be rated as clinically more
severe. The conclusion from this comparative exercise
is that as chronic, recurrent, debilitating severe
mental disorders with considerable social stigma
(Crisp et al. 2000), schizophrenia and major affective
disorders seem to be associated with greater subjective caregiver burden than cancer. This is an important point for policy makers to consider in
prioritizing resource allocation in healthcare delivery.
One comparable study from developed countries is
the UK study (Gibbons et al. 1984), in which the
denition of overall (global) distress score was similar
to the present study's global rating of difculty with
caring for the patient. They found that for 39% of
caregivers, nancial hardship had occurred (compared
with this study's 55.8%) and 47% of UK caregivers
experienced moderate/severe strain (compared with
this study's 61%). This indicates that the objective
caregiver burden of schizophrenia and affective disorder is probably greater in Nigeria than in the UK. This is
not a surprising nding, considering the various
supports of the industrial social welfare state in the
UK, which are absent in Nigeria. However, compared
with the reports from north America and western
Europe, the Nigerian psychiatric patients were much
more likely to be living at home with their families, and
their parents were more likely to be married (Loukissa
1995; Rose 1996). Also from the responses of the

92

patients, the social support of the extended family

seemed to be evident, in line with the ndings of a
previous study (Ohaeri 1998). Perhaps the positive
impacts of these indices of family stability were
amelioration of subjective burden (majority of caregivers denied quarrels at home and social stigma) and
sharing of roles (less than 12% experienced regular
disruption of work and neglect of attention to other
family members). This indicates that, in spite of the
objective burden they experienced, these families were
mostly tolerant (Hoening and Hamilton 1966), and
therefore have the potential for playing useful roles in
community management of their mentally ill relatives.
It is noteworthy that schizophrenia and major
affective disorders were associated with markedly
similar burden scores, while caregivers of patients
who had uncooperative behavior and had psychotic
symptoms showed signicantly higher GHQ-12 (i.e.,
mental distress) scores. This result was somewhat
surprising because, although patients with psychotic
symptoms had higher clinical severity scores, they
had similar scores for weighted nancial burden,
family routine burden, and family disharmony,
compared with caregivers of patients without psychotic symptoms. One implication of this nding is
that brief direct measures of mental distress, such as
the GHQ-12, are probably more sensitive in detecting
subjective distress, especially in settings where families have developed tolerant attitudes to the patient's
condition. Another implication is that adequacy of
treatment should be relentlessly pursued as a rst step
in reducing caregiver burden. This is more so in view
of the fact that the social indices of poor disease
outcome, such as patient's marital instability and
unemployment, were associated with signicantly
higher caregiver nancial distress, greater disruption
of family routines, and higher GHQ-12 scores. The
policy implication for pharmacotherapy is that, as a
way of reducing caregiver burden in developing
countries, manufacturers and governments should
nd ways of reducing the enormous cost of the novel
`atypical' antipsychotic drugs, so that with their
higher potency and better side effect prole, they
can be made available for early effective intervention,
so as to reduce the high proportion of subjects with
persistent chronic psychotic symptoms (Ohaeri 2000).
Another highlight of the ndings is the interesting
interaction among patient's perception of social
support from the extended family network, presence
of psychotic symptoms, and caregiver mental distress.
Although caregivers of patients with psychotic symptoms showed higher GHQ-12 scores, patients from
such families perceived a wider extended family
network of social support. One interpretation of this
nding is that the families of psychotic patients were
proactive in obtaining help from the wide network of
relatives, in an attempt to cope with the problem.

Instead of giving up and abandoning the patient in

frustration, they sought assistance from the extended
family, and various members responded to their call;
hence, the patient's perception of social support. In
support of this interpretation, Rose (1996) noted that,
as the chronic nature of the illness becomes apparent,
family members may respond by increasing their
efforts to nd support for themselves and appropriate
treatment for the patient. She further noted that
families who coped effectively with mental illness
were better educated, articulate and actively engaged
in seeking help and information and had resources
that enabled them to make efforts to take care of
themselves. Although the results of a few studies did
not nd that social support was a signicant predictor
of burden (Noh and Avinson 1988), the majority of
studies indicated that practical social support ameliorated family burden (Magliano et al. 2000). The
ndings of this study support the salutary role of
social support, because a signicant predictor
of caregiver global rating of burden was the size of
family network from whom the patient expected
support. One implication of these ndings for developing countries where there are no immediate hopes
for national social welfare programs is that researchers and policy makers should focus on articulating
measures that can strengthen extended family relations, as a way of providing social support and
reducing caregiver burden (Wood et al. 1998).
Although the nancial burden score was highest,
the only signicant predictors of global burden were
disruption of family routines and high GHQ-12
scores. In the previous Nigerian study of the burden
of schizophrenia, Martyns-Yellowe (1992) noted that
the greatest burden was scored for effect on family
routines, followed by effect on family interaction;
although the only signicant difference between rural
and urban families was that rural dwelless had higher
nancial burden. One interpretation of these results is
that, in a country with severe economic hardship,
even where the caregivers seem to be tolerant, the care
giving role nevertheless diminishes family efciency
in social performance, because of the disruption of
routines of economically active members (no matter
how minimal), and the psychic distress of living with
the patient's psychotic symptoms (Charkrabarti et al.
1992; Rose 1996).
In conclusion, the ndings of this study support
the impressions in the literature that:
1. For the severe mental disorders, the presence of
psychotic symptoms, patient's uncooperative behavior, and social indices of poor disease outcome
contribute more signicantly to caregiver subjective
burden than psychiatric diagnosis per se
2. Compared with chronic severe physical illnesses,
such as cancer, severe mental disorders are associ-

93

ated with comparable levels of objective burden, but

much higher levels of subjective burden and mental
distress
3. Although there is greater evidence of family stability
and support from the extended family, the care giving
role in developing countries has the disadvantage of
lack of national social welfare programs; and there is
probably greater objective caregiver burden than in
developed countries
4. Practical social support that is evident to the patient
has the potential to reduce caregiver burden.

The implications of these conclusions have been

highlighted.
j Acknowledgements Mrs. G. Oyin Awosika interviewed the
subjects; Miss `Tosin Cole played an invaluable role in data
collection and analysis. I thank the relatives and patients who gave
of their time to be interviewed. This study was partly supported by
a University of Ibadan Senate research grant.

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