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ORIGINAL ARTICLE
Year : 2013  |  Volume : 35  |  Issue : 4  |  Page : 352-357  

Caregivers burden of patients with schizophrenia and bipolar disorder: A sectional study


1 Dr. A. V. Baliga Memorial Hospital, Udupi, Karnataka, India
2 Asha Hospital, Hyderabad, Andhra Pradesh, India

Date of Web Publication27-Nov-2013

Correspondence Address:
S Vasudeva
Dr. A. V. Baliga Memorial Hospital, V. M. Nagar, Doddanagudde, Udupi - 576 101, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0253-7176.122224

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   Abstract 

Background: Caregiving has been identified as a basic component of human nature and a primary element of close relationship. This study aims to assess the extent and pattern of burden felt by the caregivers of patients with schizophrenia in comparison with bipolar disorder. Materials and Methods: Fifty-two patients with schizophrenia and fifty-one patients with bipolar disorder attending the outpatient department were assessed in the study. The burden among the caregivers was assessed using Burden Assessment Schedule. Results: The caregivers of schizophrenia group had significantly higher total burden score as compared to caregivers of bipolar disorder. Caregivers of schizophrenia experienced significantly higher burden in area of external support, caregivers routine, and other relations. Conclusion: The extent of burden among families of schizophrenic patients is more than those of bipolar disorder. The families of patients with bipolar disorder do also experience considerable burden. The pattern of burden among families of schizophrenia and bipolar disorder is almost identical in most of the domains except for external support, caregivers routine, and other relations.

Keywords: Bipolar disorder, caregivers burden, schizophrenia


How to cite this article:
Vasudeva S, Sekhar CK, Rao PG. Caregivers burden of patients with schizophrenia and bipolar disorder: A sectional study. Indian J Psychol Med 2013;35:352-7

How to cite this URL:
Vasudeva S, Sekhar CK, Rao PG. Caregivers burden of patients with schizophrenia and bipolar disorder: A sectional study. Indian J Psychol Med [serial online] 2013 [cited 2020 May 31];35:352-7. Available from: http://www.ijpm.info/text.asp?2013/35/4/352/122224


   Introduction Top


Caregiving has been identified as a basic component of human nature and a primary element of close relationship. In India, since professional services both in public and private sectors are not adequately developed due to shortage of trained human resources and infrastructure, the family support system plays a major role in caring for people with mental illnesses. Most of the studies in this area during the past 5 decades across the world have focused on the families of patients with schizophrenia and found that the families experience significant burden due to the illness. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] Later studies on caregivers of depression showed that the relatives of patients with depressive illness also experience significant distress. [12],[13]

A study involving caregivers of bipolar disorder has shown that 93% of caregivers report moderate level of burden and 54% caregivers report severe level of burden. [14] The burden on the relatives of patients with manic and depressive symptoms is significant and at similar level; [15] severity of symptoms, difficulties in the relationship with the patients, lack of support, and stigma attached to the illness are important predictors of caregiver burden in bipolar disorder. [16]

Apart from documenting the burden due to the individual disease, few authors attempted the comparative study of burden among caregivers of schizophrenia and bipolar disorder. Both the objective and subjective burden is more in relatives of schizophrenia compared to caregivers of bipolar patients. [17] Caregivers of schizophrenia patients experience more burden than those of bipolar disorder. [18] In another study, Chadda et al., [19] revealed that patients with schizophrenia and bipolar disorder impose similar level of burden on their caregivers and they use similar types of coping methods to deal with the burden. There are not many studies which have compared the burden in the families of patients with schizophrenia and bipolar disorder; more so during the stable phase of the illness. Therefore, we studied the extent and pattern of burden felt by the caregivers of patients with schizophrenia in comparison with bipolar disorder. The null hypothesis of the study being the extent and pattern of burden is similar among the caregivers of patients with schizophrenia and bipolar disorder.


   Materials ANd Methods Top


Participants

The study was conducted in Asha hospital, a tertiary care hospital in Hyderabad, Andhra Pradesh, in southern part of India. The study was approved by institutional ethical committee. The sample was selected from consecutive outpatients attending the psychiatry service of the hospital. Patients of either gender, ranging between 18 and 55 years of age, fulfilling Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) [20] diagnosis of schizophrenia and bipolar disorder, with a minimum of 1 year of illness, and clinically stable for 3 months (clinical stability was defined as ''no major changes in medication and no hospitalization in the 3 months preceding the screening''). The ''caregiver'' was any healthy primary caregiver of the patient, aged 18 years and above, and staying with the patient during last 1 year prior to the assessment. Those patients with chronic physical and other comorbid axis-I psychiatric illness, staying away from the family for a period of more than 3 months for any reason during the last 1 year, and families with other family members having psychiatric or chronic physical illness were excluded from the study.

Measures

A sociodemographic proforma specially designed for the study was used to collect the demographic and clinical details. Socioeconomic Status Scale [21] (Tiwari et al., 2005), developed for both rural and urban communities in India, was used for assessing the socioeconomic status. The reliability of the scale was high with a correlation coefficient of 0.998. To measure caregiver burden, Burden Assessment Schedule (BAS) [22] was used. It is a 40-item structured instrument in English, which assesses both the objective and subjective burden experienced by the caregiver of chronic mentally ill patients. BAS is reported to have good interrater reliability (k 0.80) and satisfactory face value in terms of relevance of the items in measuring the caregiver burden. The criterion validity of this instrument was computed against the family burden schedule of Pai and Kapur [2] and was found to have good correlation for most of the items and ranged between 0.71 and 0.82. To measure global functional level, Global Assessment of Functioning scale, [23] a 100-point single item scale with values ranging from 1 to 100 representing the hypothetically sickest person to the healthiest, was used. MINI International Neuropsychiatric Interview, [24] a short, structured diagnostic interview, designed to diagnose DSM-IV and ICD-10 psychiatric disorders was used to confirm the diagnosis and detect any comorbid conditions. It is a relatively brief instrument and has good validity and reliability. Psychopathology in schizophrenia patients measured using Positive and Negative Syndrome Scale (PANSS). [25]

Procedure

The information regarding the primary caregiver of patients was assessed from the accompanying person. In case of nonavailability or nonconsent, the next close relative was chosen for the study. After obtaining informed consent from both the patients and the caregivers, sociodemographic and disease variables were recorded. Later, MINI was administered to patients for confirmation of the clinical diagnosis and to rule out other comorbid psychiatric illnesses. Later, schizophrenia patients were assessed using Positive and Negative Syndrome Scale. Following this, caregivers were interviewed on Burden Assessment Schedule and Global Assessment of Functioning scale (GAF). All the assessments were done by the first author, Vasudeva Sadinamne.

Statistical analysis

Statistical analysis was done using SPSS version 16. Data normality was assessed using histograms and Shapiro-Wilk test statistic. Pearson's Chi-square test was used to assess the difference between the categorical variables. Independent ''t'' test and Mann-Whitney U test were used to assess the difference between the parametric and nonparametric continuous variables, respectively. Effect sizes for BAS were reported as Cohen's d. The total burden score was calculated excluding spouse-related domain. The level of significance was set at P<0.05 (two-tailed).


   Results Top


Sample characteristics

The total intake consisted of 150 patients and their caregivers (77 of schizophrenia and 72 of bipolar disorder), out of which 47 patients and caregivers were excluded (25 from schizophrenia and 21 from bipolar disorder group) due to not meeting inclusion/exclusion criteria. Finally, 103 patients and caregivers (52 of schizophrenia and 51 of bipolar disorder) were included in the final analysis. The sample characteristics are summarized in [Table 1].
Table 1: Sample characteristics

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The mean age of patients with schizophrenia was 34.50 (standard deviation (SD): 8.65) years, which was comparable to that of bipolar disorder (37.59, SD: 11.42) years. There was no difference between the patients in terms of gender, education years, marital status, employment, age of onset of illness, duration of treatment, and number of hospitalizations. The median duration of illness was significantly higher in bipolar patients as compared to schizophrenia ( P<0.05), whereas the median duration of untreated illness was significantly higher in patients with schizophrenia ( P<0.001). The mean GAF score was significantly higher in patients with bipolar disorder ( P=0.001). The mean score on PANSS in patients with schizophrenia was 61.15 (SD: 16.10).

Among caregivers, the mean age was 48.32 (SD: 11.65) years and 47.39 (SD: 12.03) years in the schizophrenia and bipolar groups, respectively. The duration of caregiving was higher in bipolar group, though the difference was not statistically significant ( P>0.05). Both the groups were comparable in terms of gender, education years, marital status, employment, family type, and background.

Comparison of caregiver burden

The caregivers of schizophrenia group had significantly higher total burden score as compared with caregivers of bipolar disorder ( P<0.05), with small effect size (Cohen's d=0.428). There were significantly higher burden in caregivers of schizophrenia patients in domains of external support ( P<0.05, Cohen's d=0.479) and caregivers routine ( P<0.01, Cohen's d=0.539), and a trend toward higher score in other relations ( P<0.05, Cohen's d=0.380). In rest of the domains, both the groups had comparable scores. The comparisons of burden are summarized in [Table 2].
Table 2: Comparison of burden between caregivers of schizophrenia and bipolar disorder patients

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   Discussion Top


The result of the study shows that the families of both schizophrenia and bipolar disorder experience considerable burden. The extent of burden in relatives of schizophrenia was, however, significantly higher than that in bipolar disorder consistent with the earlier studies, [17],[18] though the overall effect size was small. Ohaeri et al., [26] reported that the relatives of patients with psychotic symptoms bear a greater burden. This difference cannot be attributed to sociodemographic factors as both groups were comparable. Though the bipolar disorder patients had longer duration of illness and treatment, the difference of burden was more in caregivers of schizophrenia. One of the possible reasons for the difference could be due to the fact that most of the bipolar patients were in remission, whereas schizophrenia patients were having some residual symptoms. Also, it could be due to the lower level of functioning in schizophrenia patients as compared to bipolar disorder. The longer duration of illness is likely to increase the objective burden. [27] Chronic course of schizophrenia has a greater burden. [28] Giel et al., [29] reported that families of patients with chronic illness with severe loss of insight experience higher burden. Fadden et al., [12] reported that the spouses of affective disorder, especially bipolar disorder cope with the situation better possibly due to: The episodic nature of the illness, the ability of the spouse to identify the forthcoming episode early, and the expectations of near normal functioning between episodes. In schizophrenia, even when the more florid symptoms of illness have been controlled, caregivers continue to be concerned about the patient's ability to achieve the normal gratification of social life, work life, and leisure activities. [30]

Despite the difference in global burden, the pattern of burden in various domains in both the study groups was almost similar. The two study groups differ slightly in burden with regard to the external support, caregiver routine, and other relation which was high in schizophrenia caregivers as compared to the bipolar disorder.

The external support indicates the amount of support he/she gets from the family members or friends. Family members will be hesitant to be identified as relatives of mentally ill person due to social stigma and some relatives express inability to share the problem with others as they are worried about stigma regarding the illness in the society. Rapid urbanization is leading to the emergence of more nuclear families, especially in urban areas which leads to less support from other family members and friends. The joint family system is more helpful in coping with stress; whereas, nuclear families are more vulnerable to stress. [31]

Disturbance in the caregivers' daily activities was another significant aspect of burden. Schizophrenia being a chronic illness needs long-term follow-up and caregivers have to accompany the patient every time for consultation. As a consequence, caregivers do not get time to look after their health and activities. Their behavior caused disruption of family interaction and activities and was very distressing for the caregivers of schizophrenia. [6]

Burden factor, the ''other relation'' refers to the relationship between family members and friends. As a consequence of the patient's illness, family members often develop misunderstanding among themselves in caring for the patient. The high-expressed emotion and maladaptive way of functioning were seen to be more in families, where the associated burden was high. There is often difficulty in maintaining cordial relations with friends due to constant involvement with the patient. The psychopathology of the patient like persecutory/referential ideas may cause breaks in relationship with family or friends. Similar findings were reported in previous studies. [17],[32],[33]

Our sample was largely restricted to the urban population, thus limiting generalization to rural population. Also, the cross-sectional nature of our study does not allow causal inferences. Longitudinal data might give further insight into the extent of burden among caregivers of schizophrenia and bipolar disorder. Furthermore, the caregivers' beliefs about the patients' illness may influence the level of burden, which has not been specifically addressed in our study. Additional factors may account for variation in caregivers' experience of burden such as satisfaction with other aspects of life, personality profile of caregivers, and supporting systems of the family. We did not study the emotional climate within the family and support from other members of the family and society. Future studies should focus on longitudinal relationship between the burden, mood, and also coping strategies among the caregivers.


   Conclusion Top


The extent of burden among families of schizophrenic patients is more than that of bipolar disorder. The families of patients with bipolar disorder also do experience considerable burden. The pattern of burden among families of schizophrenia and bipolar disorder is almost identical in most of the domains except in external support, caregivers routine, and other relations.


   Acknowledgment Top


The authors would like to express their thanks to Dr. Samir Kumar Praharaj, Assistant professor of Psychiatry, Kasturba Medical College for valuable comments and opinion for this manuscript. The authors also thank all my teachers of Asha hospital, Hyderabad for guidance in this study.

 
   References Top

1.Mandelbrote BM, Folkard S. Some problems and needs of schizophrenics in relation to a developing psychiatric community service. Compr Psychiatry 1961;2:317-28.  Back to cited text no. 1
    
2.Pai S, Kapur RL. The burden of the family of a psychiatric patient: Development of an interview schedule. Br J Psychiatry 1981;138:331-5.  Back to cited text no. 2
    
3.Nijhawan M, Gautham S, Gehlot PS. Who is more burden on the family? Schizophrenia or chronic physical illness. Indian J Soc Psychiatry 1985;7:202-10.  Back to cited text no. 3
    
4.Sekar CR, Rao NV, Murhty RS. The chronic mentally ill and their families. In: Bharath S, editor. Reasearch on the Families with Problems in India. vol 1. Bombay: Tata Institute of Social Sciences; 1991.  Back to cited text no. 4
    
5.Martyns Yellowe IS. The burden of schizophrenia on the family-A study from Nigeria. Br J Psychiatry 1992;161:779-82.  Back to cited text no. 5
    
6.Salleh MR. The burden of care of schizophrenia in Malay families. Acta Psychiatr Scand 1994;89:180-5.  Back to cited text no. 6
[PUBMED]    
7.Provincher HL. Objective burden among primary caregivers of persons with chronic schizophrenia. J Psychiatr Ment Health Nurs 1996;3:181-7.  Back to cited text no. 7
    
8.Schene AH, van Wijngaarden B, Koeter MW. Family care giving in schizophrenia: Domains and distress. Schizophr Bull 1998;24:609-18.  Back to cited text no. 8
[PUBMED]    
9.Lanzara D, Cosentino U, Lo Manglino AM, Lora A, Nicolo A, Rossini MS. Problems of patients with schizophrenic disorders and of their families. Epidemiol Psichiatr Soc 1999;8:117-30.  Back to cited text no. 9
    
10.Gutierrez Maldonado J, Caqueo Urizar A, Kavanagh DJ. Burden of care and general health in families of patients with schizophrenia. Soc Psychiatry Psychiatr Epidemiol 2005;40:899-904.  Back to cited text no. 10
    
11.Mangliano L, Fiorillo A, De Rosa C, Maj M. National Mental Health Project Working Group. Family burden and social network in schizophrenia vs physical diseases: Preliminary results from Italian national study. Acta Psychiatr Scand Suppl 2006;1:60-3.  Back to cited text no. 11
    
12.Fadden G, Bebbington P, Kuipers L. Caring and its burden: A study of the spouses of depressed patients. Br J Psychiatry 1987;151:660-7.  Back to cited text no. 12
[PUBMED]    
13.Birtchnell J, Kennard J. Does marital maladjustment lead to mental illness? Soc Psychiatry 1983;18:79-88.  Back to cited text no. 13
[PUBMED]    
14.Perlick D, Clarkin JF, Sirey J, Raue P, Greenfield S, Struening E, et al. Burden experienced by care-givers of person with bipolar affective disorder. Br J Psychiatry 1999;175:56-62.  Back to cited text no. 14
[PUBMED]    
15.Schmid R, Huttel GU, Gording C, Spiessl H. The situation of caregivers of inpatients with bipolar affective disorders. Fortschr Neurol Psychiatr 2007;75:665-72.  Back to cited text no. 15
    
16.Van der Voort TY, Goosens PJ, Van der Biji JJ. Burden, coping and needs for support of caregivers for patients with bipolar disorder: A systematic review. J Psychiatr Ment Health Nurs 2007;14:679-87.  Back to cited text no. 16
    
17.Chakrabarti S, Raj L, Kulhara P, Avasthi A, Verma SK. Comparison of the extent and pattern of family burden in affective disorder and schizophrenia. Indian J Psychiatry 1995;37:105-12.  Back to cited text no. 17
[PUBMED]  Medknow Journal  
18.Roychaudhuri J, Mondal D, Boral A, Bhattacharya D. Family burden among long term psychiatric patients. Indian J Psychiatry 1995;37:81-5.  Back to cited text no. 18
[PUBMED]  Medknow Journal  
19.Chadda RK, Singh TB, Ganguly KK. Caregiver burden and coping: A prospective study of relationship between burden and coping in caregivers of patients with schizophrenia and bipolar disorder. Soc Psychiatry Psychiatr Epidemiol 2007;42:923-30.  Back to cited text no. 19
[PUBMED]    
20.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Text Revision 2000. 4 th ed. Washington, DC: American Psychiatric Association.  Back to cited text no. 20
    
21.Tiwari SC, Kumar A, Kumar A. Development and standardization of a scale to measure socio-economic status in urban and rural community in India. Indian J Med Res 2005;122:309-14.  Back to cited text no. 21
    
22.Thara R, Padmavathi R, Kumar S, Srinivasan L. Burden assessment schedule. Instrument to assess burden on caregivers of chronic mentally ill. Indian J Psychiatry 1998;40:21-9.  Back to cited text no. 22
[PUBMED]  Medknow Journal  
23.Endicott J, Spitzer RH, Fleiss JL, Cohen J. The global assessment scale: A procedure for measuring overall severity of psychiatric disturbance. Arch Gen Psychiatry 1976;33:766-71.  Back to cited text no. 23
    
24.Sheehan BV, Lecrubier Y, Sheehans KH. The Mini International Neuropsychiatric Interview (MINI): The development and validation of structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59:22-33.  Back to cited text no. 24
    
25.Kay SR, Fiszben A, Opler LA. The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophr Bull 1987;13:261-76.  Back to cited text no. 25
    
26.Ohaeri JU. Caregiver burden and psychotic patients perception of social support in a Nigerian setting. Soc Psychiatry Psychiatr Epidemiol 2001;36:86-93.  Back to cited text no. 26
[PUBMED]    
27.Hoenig J, Hamilton MW. The schizophrenic patients in the community and his effects on the household. Int J Soc Psychiatry 1966;12:165-76.  Back to cited text no. 27
[PUBMED]    
28.Brown GW, Bone M, Dalison B. Schizophrenia and social care. London: Oxford University Press; 1966.  Back to cited text no. 28
    
29.Giel R, de Arango MV, Hafeiz Babikir A, Bonifacio M, Climent CE, Harding TW, et al. The burden of mental illness on the family: Results of observation from four developing countries. Acta Psychiatr Scand 1983;68:186-201.  Back to cited text no. 29
[PUBMED]    
30.Perlick DA, Rosenheck RA, Kaczynski R, Swartz MS, Cañive JM, Lieberman JA. Components and correlates of family burden in schizophrenia. Psychiatr Serv 2006;7:1117-25.  Back to cited text no. 30
    
31.Sethi BB, Manchanda R. Socioeconomic, demographic and cultural correlates of psychiatric disorders with special reference to India. Indian J Psychiatry 1978;20:199-211.  Back to cited text no. 31
  Medknow Journal  
32.Gautham S, Nijhawan M. Burden on families of schizophrenia and chronic lung disease patients. Indian J Psychiatry 1984;26:156-9.  Back to cited text no. 32
    
33.Creer C, Sturt E, Wykes T. The role of relatives. In long term community care: Experience in a London borough (Ed. J. K. Wing). Psychol Med 1982; Monograph Suppl 2.  Back to cited text no. 33
    



 
 
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