Global Burden of Disease (GBD) study 2017 reports that around 13 percent of the world population i.e., 970 million, have been suffering from mental illnesses of which 310 million are suffering from Mood disorders [1]. Mental illness is characterized by disturbance in cognition, emotional regulation, and behavioural functioning resulting in enormous social and economic burden to the affected individuals, their families, and communities [2].

An integral part of the care system for people with chronic mental illnesses is family [3]. In India, the family support system plays a significant role in caring for people with mental illnesses as professional services are not adequately developed in public and private sectors due to a shortage of skilled human resources and infrastructure [4]. A caregiver has been defined as “a family member, who has been staying with the patient for more than a year and has been closely related with the patient's daily living activities, discussions, and care of health.” [5].

The caregivers often play multiple roles in caring for persons with mental illness, including taking day-to-day care, supervising their medications, taking the patient to the hospital, and looking after the financial needs thus experiencing considerable burden and stress and hence need help to cope with it. The caregiver burden is a universal phenomenon. Studies show that almost 80% of caregivers experience a burden in their caregiving role [6].

In the case of caregivers who provide long-term care for individuals with chronic mental illness, psychological or economic difficulties can be seen. These difficulties can lead to emotional disturbances such as burden, depression, anxiety, burnout, impaired physical health, social isolation and economic difficulties [7]. Goldstein, Miklowitz, and Richards reported that 44% of caregivers of individuals with chronic mental illness have anxiety disorders [8]. Steele, Maruyama, and Galynker reported in a systematic review that depression occurred in 46% of caregivers of persons with mental illness [9].

The present study aimed to explore the burden experienced by the caregivers of patients with mood disorders, assess the psychiatric morbidity of caregivers, and explore the association between caregivers’ burden and psychiatric morbidity in a rural setting.

This is a comparative cross-sectional study done on primary caregivers of clinically diagnosed patients with mood disorders attending the psychiatry department at a tertiary care teaching hospital located in a rural area after taking written informed consent. The Institutional ethical review committee approved this study. Data was collected over 18 months from January 2019 to June 2020. The sample size was calculated based on a study by Parija S [10].

A minimum Sample size of 47 was deemed adequate. However, at least 60 subjects were considered for evaluation keeping attrition in view. Criteria for inclusion were caregivers of patients with mood disorders living with the patients and caring for them for at least 1 year after diagnosis and aged above 18 years, at the time of study. Caregivers of patients with mood disorders secondary to chronic medical illnesses or substance abuse disorders and caregivers of patients with schizoaffective disorders were excluded.

All the caregivers were given a specially prepared proforma which contained information about socio-demographic details like age, gender, education, occupation, monthly income, type of family, relationship to patient, duration of caregiving, and patient illness.

Burden Assessment Schedule (BAS) [11], developed by Thara and was used to assess both the objective and subjective burden experienced by the caregivers of mentally ill patients. BAS has been reported to have good inter-rater reliability (κ 0.80) and satisfactory face validity in terms of the relevance of the items in measuring caregiver burden.

Mini International Neuropsychiatric Interview (MINI) [12] was used to assess psychiatric morbidity. MINI is a short structured diagnostic interview, developed jointly by psychiatrists and clinicians in the United States and Europe, for DSM-IV and ICD-10 psychiatric disorders and comprises modules for 17 psychiatric diagnoses.

The data was entered into the Microsoft Excel 2007 version and further analysed using Statistical Package for the Social Sciences (SPSS) v. 20 applying the chi-square test and Fisher-Freeman-Halton test and a P value of < 0.05 was considered to be statistically significant.

A total of 62 caregivers has been assessed. Majority of the caregivers were older than 50 years (43.55%) and a majority of the caregivers were male (56.45%). Majority of the caregivers were illiterate (41.94%) and unskilled workers (40.32%). Most of the caregivers (53.23%) belonged to lower socio-economic class. Majority of the caregivers (51.61%) were spouses of the patients (Table 1).

The duration of caregiving varied among the caregivers. More caregivers were providing care for ≤ 7 years (67.74%). Majority were the caregivers of patients suffering from recurrent depressive disorder (43.55%). The burden assessment scores were found to be mild in 62.90% of the population followed by moderate (29.03%) and severe (8.06%) (Table 2).

Around half of the caregivers (50%) have not experienced any psychiatric morbidities. Among the other half, a majority (22.58%) have experienced Dysthymia followed by alcohol use disorders (11.29%), Major depressive disorder (8.06%) and panic and anxiety disorders (8.06%) (Table 3).

Table 1: Socio demographic distribution of caregivers.

Table 2: Frequency Distribution of Other parameters and Burden Assessment Scores.

Table 3: Frequency Distribution of Psychiatric Morbidities in Caregivers.

Among the caregivers, 73.49% (n=31) of the caregivers with mild BAS scores had no psychiatric morbidities. Forty-four percent (n=8) and 27.78% (n=5) of the caregivers with moderate scores had screened for dysthymia and alcohol disorders respectively. Among the caregivers with severe BAS scores, 60% (n=3) had MDD. There was a statistically significant association found between BAS scores and psychiatric morbidities in mood disorders group (p=0.000) (Table 4).

Duration of caregiving was found to be significantly associated with psychiatric morbidities(p=0.000) with 68.18% of caregivers providing care for 2-4 years did not screen for any psychiatric morbidities whereas 66.67% and 33.33% of caregivers providing care for >10 years screened for dysthymia and MDD respectively (Table 5).

Duration of Caregiving was also found to be significantly associated (p=0.000) with BAS scores with 77.27% of caregivers providing care for 2-4 years having mild BAS scores and 50% of the caregivers providing care for > 10 years having severe BAS scores (Table 6).

Table 4: Association of Burden Assessment Scores with Psychiatric Morbidities.

Table 5: Association of Duration of Caregiving with Psychiatric Morbidities.

Table 6: Association of Duration of Caregiving and Burden Assessment Scores.

Caregiver burden is a universal phenomenon. Research defining caregiver burden began in the 1960s. Grad and Sainsbury (1963) measured burden as any cost to the family. Zarit, Reever, and Bach-Peterson (1980) conclude it is the characteristics of the caregiving situation and availability of resources, rather than the condition of the recipient that have a direct relationship to the well-being of the caregiver. George and Gwyther (1986) reinforced Zarit’s definition they found that physical, psychological, emotional, social, and financial problems are all related to caregiver burden [13].

Caregiving has been identified as a chronic stressor that places caregivers at risk for physical and emotional problems [14]. The negative impact of caregiving on the caregivers' mental health is widely substantiated in the literature. Approximately 30% of caregivers reported that caregiving has affected their well-being and that they were often worried or depressed in data collected by the Australian Bureau of Statistics (ABS) [15]. A review of 41 studies published between 1990 and 1995 focused on the effects on caregivers of people with dementia. This review reported increased levels of psychiatric morbidity and higher levels of depression among caregivers [16].

In the present study, we have assessed 62 caregivers of patients with mood disorders for caregiver burden and associated psychiatric morbidities. The mean BAS score of the caregivers was 50.58 ± 18.58. Similar results have also been observed by Vasudeva, Sekhar and Rao who conducted a comparative study between caregivers of schizophrenia and bipolar patients which showed mean BAS scores of 68.75 ± 8.76 and 64.45 ± 10.14 respectively in caregivers of schizophrenia and bipolar patients [17]. A comparative study of family burden in caregivers of chronic schizophrenia and bipolar affective disorder done by Bora and Das (2017) found that mean B.A.S. score for Chronic Schizophrenia group was 102.86 ± 27.04 whereas the mean B.A.S. score for the B.P.A.D. group was 88.80 ± 22.31 which was similar to our study [18].

In the present study, we have observed that half of the caregivers did not suffer from any psychiatric morbidities. But the remaining half have screened for psychiatric morbidities. Among them, 22.58% have screened for and 8.06% for Major depressive disorder which accounts for a total of 30.64% of the caregivers screening positive for depressive disorders which was similar to 30% of caregivers reporting distress in study done by Goossens, Van Wijngaarden, Knoppert-van Der Klein and Van Achterberg in 2008 [19]. Similar results like 46% of the partners of bipolar patients had experienced depressive symptoms in the study done by Lam, Donaldson, Brown and Malliaris in 2005 [20].

Around 73% of the caregivers with mild burden did not screen for any psychiatric morbidities. Whereas all the caregivers experiencing moderate burden and severe burden have screened positive for psychiatric morbidities. The present study also reveals a significant association (p<0.001) between the burden and psychiatric morbidities among the caregivers. These results were on par with the previous studies conducted by Perlick, Berk, Kaczynski, et al (2016) [21] in which they assessed a causal relationship between caregiving burden and depressive symptoms and found that the level of burden has significantly influenced the depression in the caregivers of patients with bipolar disorder.

In addition to the above findings, we have also observed that the duration of caregiving was significantly (p<0.05) associated with the presence of psychiatric morbidities. Around 68.18% of caregivers providing care for 2-4 years did not screen for any psychiatric morbidities whereas 66.67% and 33.33% of caregivers providing care for >10 years screened for dysthymia and MDD respectively.

We also found a statistically significant association between duration of caregiving and burden assessment scores in our study with 77.27% of caregivers providing care for 2-4 years having mild BAS scores and 50% of the caregivers providing care for > 10 years having severe BAS scores. Similarly, Bora, Das and Deka (2017) [22] in their study found that those with duration of care of ten or more years experienced more caregiver burden.

This study has revealed a significant burden among the caregivers of patients with mood disorders and also a higher prevalence of psychiatric morbidities among them. There was also a significant association found between burden and psychiatric morbidities. These findings emphasize the need for the identification of burden on the caregivers of patients with mood disorders so that they are not adversely affected by it. This also stresses the need to strategize interventions focusing not only on the patients but also involving the caregivers which are feasible with the available infrastructure and resources.

The present study has certain limitations. The sample size was modest and the study was done in a hospital setting hence the results cannot be generalized to a wider population. Rater bias could not be completely excluded as the examiners who applied BAS and MINI were not blind to the diagnosis.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

None.

1. World Health Organisation. Global Burden of Disease. 2017.
2. Ayalew M, Workicho A, Tesfaye E, Hailesilasie H, Abera M. Burden among caregivers of people with mental illness at Jimma University Medical Center, Southwest Ethiopia: a cross-sectional study, Ann Gen Psychiatry. 2019; 18: 10.
3. Rammohan A, Rao K, Subbakrishna DK. Burden and coping in caregivers of persons with schizophrenia, Indian J Psychiatry. 2002; 44: 220-227.
4. Nallapaneni NR, Yendluri P, Paritala CBG, Racharla BN. A study of caregiver burden in bipolar affective disorder, J of Evolution of Med and Dent Sci. 2015; 4.
5. Swaroop N, Ravi S, Goud BR, Archana M, Pius TM, Pal A, et al. Burden among Caregivers of Mentally- Ill Patients: A Rural Community - Based Study, Int J Res Dev Health. 2013; 1.
6. 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 affective disorder. Soc Psychiatry Psychiatr Epidemiol. 2007; 42: 923-930.
7. Bademli K. Anxiety and Depression in Caregivers of Chronic Mental Illness. J Depress Anxiety. 2017; 6: 254.
8. Goldstein TR, Miklowitz DJ, Richards JA. Expressed emotion attitudes and individual psychopathology among the relatives of bipolar patients. Family Process. 2002; 41: 645-657.
9. Steele A, Maruyama N, Galynker I. Psychiatric symptoms in caregivers of patients with bipolar disorder: a review. J Affect Disord. 2010; 121: 10-21.
10. Parija S, Yadav AK, Sreeraj VS, Patel AK, Yadav J. Burden and Expressed Emotion in Caregivers of Schizophrenia and Bipolar Affective Disorder Patients: A Comparative Study. MAMC J Med Sci. 2018; 4: 68-74.
11. Thara R, Padmavati R, Kumar S, Srinivasan L. Burden assessment schedule. Instrument to assess burden on caregivers of chronic mentally ill. Indian J Psychiatry. 1998; 40: 21-29.
12. Sheehan DV, Lecrubier Y, Sheehans KH, Amorim P, Janavs J, Weiller E, et al. 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.
13. Hoffmann RL, Mitchell AM. Caregiver burden: historical development. Nurs Forum. 1998; 33: 5-11.
14. Aneshensel CS, Pearlin LI, Mullan JT, Zarit SH, Whitlatch CJ. Profiles in caregiving: The unexpected career. San Diego: Academic Press. 1995.
15. Australian Bureau of Statistics (ABS). Disability, ageing and carers, Australia: Summary of findings 1998, Australian Bureau of Statistics. Canberra. 1998.
16. Schultz RA, OBrien T, Bookwala J, Fleissner K. ‘Psychiatric and physical morbidity effects of dementia caregiving: Prevalence, correlates, and causes’. The Gerontologist. 1995; 35: 771-791.
17. Vasudeva S, Sekhar CK, Rao PG. Caregivers burden of patients with schizophrenia and bipolar disorder: a sectional study. Indian J Psychol Med. 2013; 35: 352-357.
18. Bora K, Das A. Family Burden in Caregivers of Chronic Schizophrenia and Bipolar Affective Disorder. A Comparative Study. JMSCR. 2017; 5.
19. Goossens PJJ, Wijngaarden BV, Knoppert-Van Der Klein EAM, Achterberg TV. Family caregiving in bipolar disorder: caregiver consequences, caregiver coping styles and caregiver distress. Int J Soc Psychiatry. 2008; 54: 303-316.
20. Lam D, Donaldson C, Brown Y, Malliaris Y. Burden and marital and sexual satisfaction in the partners of bipolar patients. Bipolar Disord. 2005; 7: 431-440.
21. Perlick DA, Berk L, Kaczynski R, Gonzalez J, Link B, Dixon L, et al. Caregiver burden as a predictor of depression among family and friends who provide care for persons with bipolar disorder. Bipolar Disord. 2016; 18: 183-191.
22. Bora K, Das A, Deka K. Family Burden and Coping in Caregivers of Bipolar Affective Disorder. A Hospital Based Study. Sch J App Med Sci. 2017; 5: 4162-4170.