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Year : 2013  |  Volume : 12  |  Issue : 2  |  Page : 135-139  

Prevalence of psychiatric morbidity using GHQ-28 among cleft lip patients in Sokoto

Department of Psychiatry, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

Date of Web Publication22-May-2013

Correspondence Address:
Mufutau A Yunusa
Department of Psychiatry, Usmanu Danfodiyo University Teaching Hospital, Sokoto
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1596-3519.112414

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Background: In the management of cleft lip, attention is usually focused on physical deformity and functional anomaly. Previous studies on psychiatric morbidity challenged this position. However, most of these studies were from western society. Few studies have reported on the prevalence of psychiatric morbidity among adult Nigerian patients with cleft lip.
Materials and Methods: In this prospective cross-sectional study, 200 patients with cleft lip, who were between the age of 20 and 39 years, were assessed using standardized semistructured psychiatric instrument. Additionally, 100 healthy subjects matched for gender and educational attainment served as control. A questionnaire related to sociodemographic variables was designed and administered to the two groups. GHQ-28 was used to assess for the presence of psychiatric morbidity. Graphpad instat was used for data analysis.
Result: More than a quarter of the patients have psychiatric morbidity which was greater than the control (P<0.001). Sociodemographic attributes associated with high psychiatric morbidity include male gender (P=0.0018), widowhood (P<0.0001), age group 30--34 years (P<0.0001), and being unemployed (P=0.001).
Conclusion: In addition to reconstructive surgery, psychiatric evaluation and intervention would be of benefit in the management of cleft lip patients.

   Abstract in French 

Fond: Dans la gestion d'une fente labiale, attention est habituellement centrée sur la déformation physique et anomalie fonctionnelle. Des études antérieures sur la morbidité psychiatrique a contesté cette position. Cependant, la plupart de ces études proviennent de la société occidentale. Peu d'études ont rendu compte de la prévalence de la morbidité psychiatrique chez les adultes atteints nigérians de bec-de-lièvre.
Méthodes et matériaux: Dans cette étude transversale prospective, 200 patients avec une fente labiale, qui étaient âgés de 20 à 39 ans, ont été évalués à l'aide d'instrument psychiatrique semi-structurées normalisé. En outre, 100 sujets bien portants appariés pour le sexe et le niveau de scolarité servent de témoin. Un questionnaire relie aux variables sociodémographiques a été conçu et administré aux deux groupes. GHQ-28 a été utilisé pour évaluer la présence de la morbidité psychiatrique. GraphPad instat a été utilisé pour l'analyse des données.
Résultat: Plus d'un quart des patients ont une morbidité psychiatrique qui était plus grande que le contrôle (P< 0,001). Sociodémographiques attributs associés à une morbidité psychiatrique élevée incluent le sexe masculin (P= 0,0018), veuvage (P< 0,0001), groupe d'âge 30 - 34 ans (P< 0,0001) et étant au chômage (P= 0,001).
Conclusion: En plus de la chirurgie reconstructive, évaluation psychiatrique et intervention serait bénéfique dans le traitement des patients de bec-de-lièvre.
Mots clés: Une fente labiale, morbidité, prévalence, psychiatrique, sociodémographiques

Keywords: Cleft lip, morbidity, prevalence, psychiatric, sociodemography

How to cite this article:
Yunusa MA, Obembe A. Prevalence of psychiatric morbidity using GHQ-28 among cleft lip patients in Sokoto. Ann Afr Med 2013;12:135-9

How to cite this URL:
Yunusa MA, Obembe A. Prevalence of psychiatric morbidity using GHQ-28 among cleft lip patients in Sokoto. Ann Afr Med [serial online] 2013 [cited 2023 Sep 22];12:135-9. Available from:

   Introduction Top

Facial cleft is among the most frequent congenital anomalies [1],[2],[3] and frequently associated with psychiatric morbidity. The facial disfigurement could be stressful enough to result into psychiatric morbidity. [4],[5],[6] In addition, genetic variations which supported the anomaly could contribute to the disorder. The recent finding of increased prevalence of schizophrenia in patients with Velocardiofacial syndrome further supported this observation. [7] Previous studies have reported on psychological morbidity among patients with cleft lip. [8],[9],[10],[11] In a study of 228 Norwegian adults with cleft lip, 45% of the subjects reported that they had often or sometimes been troubled by anxiety compared with only 21% of 1318 control subjects. In addition, about twice as many subjects with cleft lip reported frequent or occasional psychological problems during the previous 6 months when compared with the control. [11] However, one study reported that the cleft lip was not necessarily associated with increased psychiatric morbidity. [12]

A Danish population study [13] among 6462 patients with cleft lip showed that 284 (4.4%) were admitted for psychiatric disorders. The relative risk of hospitalization being 1.65 (95% confidence interval 1.3-2.0) and 1.15 (confidence interval 0.99-1.29) for cleft palate and cleft lip, respectively. [10] This suggested that individuals with cleft palate may have increased risk of psychiatric disorders than patients with cleft lip. Their study was mainly among individuals with severe psychiatric morbidity requiring admissions such as schizophrenia, bipolar disorder, substance use disorder, autism and mental retardation, and in western society.

Psychiatric morbidity has been little investigated particularly in northern Nigeria. The present study was to determine the prevalence of psychiatric morbidity among adult patients with facial cleft in Sokoto using GHQ-28.

   Materials and Methods Top

This prospective, cross-sectional, controlled study was conducted after obtaining ethical approval from the research ethics committee of the native institution of the researchers which was the only institution with established ethical committee in Sokoto during the study period. In addition, permission was obtained from the management of the participating hospital after having given the study proposal to the management for perusal.


The study took place in Noma Children Hospital (NCHS) Sokoto. While the hospital derived its name from cancrum oris (Noma), it also manages other conditions such as cleft lip. The majority of the patients were from the north western Nigeria (Sokoto, Kebbi, and Zamfara states), and other states including neighboring country such as Republic of Niger. Data were collected over a period of 6 months from March 2006 to September 2006.

A total of 200 consecutive adult patients with cleft lip for surgery were recruited for the study. Inclusion criteria included giving consent, being of age group 20-39 years, ability to read or understand English or Hausa, and the presence of cleft lip with or without cleft palate. Exclusion criteria included the presence of overt or past psychiatric ailment. In addition, the questionnaire had a section for the patients to give consent where a patient was literate enough; however where a patient had no formal education, oral consent was obtained from individual patient. Patients who did not volunteer to participate were not denied appropriate treatment.

Instruments used

A sociodemographic questionnaire was designed by the authors and used to assess in the area of basic sociodemographic variables including age, sex, occupation, marital status, and education attainment. A General Health Questionnaire (GHQ) - 28 [14] was used to assess for the presence of psychiatric morbidity. The GHQ was derived from an extensive study from older instruments namely, Cornell Medical Index, Taylors' Manifest Anxiety Scale, Eysencks Personality Inventory, and the Minnesota Multiphasic Personality Inventory. [14] The original version was 60-item instrument. However, the shorter versions including GHQ-30 and GHQ-12 have been produced. GHQ-28 was produced by factor analysis of GHQ-60. [13] The scoring technique includes discriminant function analysis, GHQ scoring, modified Likert, and Simple Likert. Although Likert scoring encompasses both area and intensity while the GHQ scoring method only covers area, there is relatively little advantage in considering intensity. The GHQ scoring method being bimodal response eliminates any error due to "end users" and "middle users" since they will score the same irrespective of whether they tend to prefer columns 1 and 4 or columns 2 and 3 to indicate the presence or absence of the item in question. This instrument is self-administered.

The GHQ-28 has a total score of 28 using the GHQ scoring technique. It has been validated and extensively used in research studies in Nigeria. [15],[16],[17] The instrument is a very important tool as it detects psychological symptoms which do not reach diagnostic threshold. [15] The GHQ-28 has four subscales, namely anxiety and insomnia, social dysfunction, severe depression, and somatic symptom. [14] Both the English and Hausa version were used. The latter was used for patients who could not understand English. In addition, where the respondents had no formal education, the instrument was administered by the investigator and Hausa speaking assistants who had been trained on the use of the instrument. The GHQ scoring technique was used and the cut-off score was put at 5, [18] implying that a patient who has a score of ≥5 is defined as having psychiatric morbidity. For homogeneity of the results, no explanation was given to the patients on GHQ-28 items. Also, the scoring was performed by one of the researchers. The data were analyzed using Graphpad instat. Continuous values were stated as means ± standard deviation while categorical data were expressed as percentages. Mean value of the two groups were determined using the Students t-test and P < 0.05 was considered statistically significant.

   Results Top

Two hundred patients with cleft lip were assessed for psychopathology. As shown in [Table 1], the age range was between 20 and 39 years while the mean age of the patients was 27.75 years (±6.28 years). One hundred and thirty three (66.5%) were females while 67 (33.5%) were males. Eighty seven (43.5%) were never married while 90 of them (45%) were married. Majority of the patients were Muslims (93%) while 7% were Christians. In addition, the patients were found to have low educational attainment. Their occupational status showed that 62 (31%) were unemployed while 138 (69%) were employed comprising both skilled (7%) and unskilled (93%). This study showed that the prevalence of psychiatric morbidity among the patients was 28.5%.
Table 1: Sociodemographic characteristics of the patient with cleft lip and control

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[Table 2] showed that forty-eight percent of the patients of the age group 30-34 years had psychopathology. This was more than the prevalence in the other age groups. With regard to gender, more male patients were found to have psychopathology than their female counterparts, the difference being statistically significant (χ2 = 9.742; P = 0.002). The prevalence of psychopathology among the widowed patients was also found to be higher than the prevalence in other groups. In addition, one-third of the patients with no formal education had psychopathology. This was similar to the prevalence rate among patients with only primary school education, the difference being not statistically significant (P = 0.915; χ2 with Yates correction = 0.012). In terms of occupation, the prevalence of psychiatric morbidity among unskilled patients was 64.5%.
Table 2: Sociodemographic factors of cleft lip patients and psychiatric morbidity

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   Discussion Top

Noma Hospital is the only such hospital in Nigeria. To our knowledge in northern Nigeria, this is the first study on psychiatric morbidity in cleft lip patients. The prevalence of psychiatric morbidity was high (28.5%) and about twice that of the control. A study has reported similar finding [11] but a higher prevalence of psychiatric morbidity. In addition, psychiatric morbidity including anxiety, depression, and palpitation was about twice that of control, a finding similar to the present study. However there were some methodological differences in the two studies. While patients in the present study were recruited preoperatively, their patients were recruited postoperatively. In addition, the present study used GHQ-28 to assess for psychiatric morbidity but in their study, they did not use any structured psychological instrument.

Some studies have similarly reported on psychiatric morbidity among patients with cleft lip. Tisza et al., [19] at the cleft palate Institute of Tufts University in 1955 reported on 20 cases, 3-6 months after the completion of diagnostic evaluation. They found a higher degree of muscle tension and rigidity among the subjects. However their study could not ascertain whether the muscle tension was simply reaction to the hospital setting or personality as there was no control group. A previous study [20] also reported among 55 patients with cleft. There was situational concern related to appearance, excessive inhibition of personality adaptation, concern regarding physical appearance, and dissatisfaction. In addition, another study showed that cleft lip patients have social phobia requiring treatment [21] while suicide rate was reported to be high in one study. [5]

Unlike the present study which was among adult patients, some other studies have reported among children. In a retrospective study by Gluck et al., [22] among 292 children from a guidance center, cleft patients have greater tendency to be shy and a higher incidence of enuresis. Also, in a study of 34 cleft and noncleft lip children using the Piers-Harris self-concept scale, [23] cleft lip children significantly scored lower especially among the females. This lower score among the female was attributable to external reaction or greater sensitivity to physical appearance. In one study, [24] psychiatric morbidity was investigated among 55 cleft lip children using a nonverbal personality test, the Missouri children's picture series. There was excessive inhibition of impulse when compared to orthopedic handicapped children. In addition the children have tendency to avoid social situations, getting married later in life, and having fewer children. [25],[26]

More male patients were observed to suffer from psychiatric morbidity than the female. This observation concurred with findings from other study. [11] Other factors associated with high psychiatric morbidity include being older and having lost a partner.

The findings from the present study should be interpreted with caution while considering the following limitations. This was a hospital-based study and hence cannot represent the general community. Also as the patients were recruited preoperatively, the concern whether they will make the list of patients to be operated could inflate the finding.

While the present study supported the findings of previous studies, research findings have not translated into improved care for these patients. Hence psychiatric morbidity remained an unmet need of patients with cleft lip. In a survey of mental health service offered by the cleft/craniofacial team, [27] psychology was not represented in 60% of the 195 teams studied while psychiatry was not represented in 86%. Twenty percent of the "team" director did not perceive mental health service as important to the treatment of the patient with cleft.

In addition, the use of GHQ-28 in this study which is a self-administered instrument suggested that this instrument may be used routinely in the busy surgeons' clinic. Any patient that is positive for psychiatric morbidity using this instrument may then be referred for further evaluation and management.

For future study, there is a need for community-based longitudinal study. In addition, this cross-sectional study suggested that not all the patients will develop psychiatric morbidity. Further identification of the factors that protect from psychological distress would enable professionals to screen families for those specific factors and establish intervention strategies to provide support to the families.

   Acknowledgments Top

The authors appreciate the kind support of the former Medical Director of Noma Children Hospital, Sokoto (NCHS) Dr. H. Salter, Dr. S.A. Adeniyi (NCHS) and his family member, the management and the staff of the hospital for their kind moral support during the study.

   References Top

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11.Ramstad T, Ottem E, Shaw WC. Psychosocial adjustment in Norwegian adults who had undergone standardized treatment of complete cleft lip and palate. II. Self-reported problems and concerns with appearance. Scand J Plast Reconstr Surg Hand Surg 1995;29:329-36.  Back to cited text no. 11
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  [Table 1], [Table 2]

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