Current Health Sciences Journal Vol. 45, No.

3, 2019 July-September

Original Paper
Factors that Impact Caregivers of Patients with
Schizophrenia
LIVIA MIHAELA STRUNOIU1, CRISTIAN MARIAN STRUNOIU2,
ANCA LIVIA CHIRITA3, MIHAIL CRISTIAN PIRLOG4, ANDREI ADRIAN TICA5
1
Doctoral School, University of Medicine and Pharmacy of Craiova, Romania,
Outpatient Psychiatric Unit, Municipal Hospital “Filantropia” Craiova, Romania
2
Department of Psychiatry, Slatina Emergency County Hospital, Romania
3
Department of Psychiatry, University of Medicine and Pharmacy of Craiova, Romania
4
Department of Sociology, University of Medicine and Pharmacy of Craiova, Romania
5
Department of Pharmacology, University of Medicine and Pharmacy of Craiova, Romania

ABSTRACT: Schizophrenia, a term first introduced by Eugen Bleurer in 1911, is a controversial topic, a symbol of
profound behavioral and personality disorders. Although schizophrenia mainly affects the patients, directly, it
indirectly affects their caregivers. Because caregivers of subjects with schizophrenia experience significant burden in
taking care of the patient, usually over a long period of time, we decided to analyze some of the factors that can
impact the perceived level of stress. Our study group consisted of caregivers 124 patients with schizophrenia,
interviewed between January 2018 and July 2019. We analyzed demographic, clinical and other medical variables of
patients and caregivers. We also evaluated caregivers’ burden, using the adapted Zarit interview. The average Zarit
score in our study was 42.36±8.64, which shows moderate to high burden. Several factors that influence the
perceived burden of the caregiver have been identified, such as patient gender, age of onset, patient and caregiver
marital status, patient level of education and social functioning, caregiver age, somatic comorbidities and therapeutic
compliance of the patient.

KEYWORDS: Schizophrenia, caregivers, burden, adapted Zarit interview

unemployment is extremely high at 80-90%
Introduction [6,7] and life expectancy is reduced by
Schizophrenia, a term first introduced by 10-20 years [8,9].
Eugen Bleurer in 1911, is a controversial topic, a Especially in later years, it was proven that
symbol of profound behavioral and personality schizophrenia is treatable. Psychosocial support
disorders. The question was raised whether and various treatments with new types of drugs
"schizophrenia is the most serious disease were proved to be effective, but the main
affecting humanity, without excluding AIDS" problem is that the majority of people with
(Erlenmeyer, 1993) [1]. It is estimated that, schizophrenia, because of poor social support
worldwide, 21 to 23 million people are affected and adherence to treatment, in the end lack
by this chronic, severe mental disorder [2]. It’s access to continuous, correctly provided therapy.
prevalence is about 4.6-5/1000 in the general Antipsychotics are widely used in the
population, with various studies reporting management of patients with schizophrenia. The
prevalence rates between 2.7 and 8.3/1000 [3,4]. introduction of second-generation or "atypical"
It is a known fact that schizophrenia is antipsychotics has expanded the use of this drug
gender related, being more common among class, being considered more effective in
males than females, with a ratio of 4:3 in favor treating certain symptoms and being better
of males, and some studies suggests that the tolerated than those in the first generation
onset is earlier among men [5]. [10,11]. Although better tolerated, they are still
Schizophrenia has a major impact in quality associated with metabolic, cardiovascular or
of life, being associated with considerable neurological adverse effects, leading to
disability and usually it affects educational and discontinuation of treatment by patients and low
occupational performance. It was estimated that therapeutic compliance, which represents the
patients with this disease are 2-3 times more concordance between the indications and the
likely to die early than the general population, prohibitions formulated by the doctor and their
because of an increased risk of physical effective application by the patient [11-15].
illnesses, such as metabolic, cardiovascular and Atypical antipsychotics are also called
infectious diseases [2]. The rate of second generation antipsychotics. They are

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Livia Mihaela Strunoiu et al. - Factors that Impact Caregivers of Patients with Schizophrenia

dopaminergic receptor antagonists D2, (D2, D3, of treatment and support needed by patients with
D4), and D1, D5; 5HT2 serotoninergic, this kind of mental disorder. The engagement of
nicotinic, muscarinic and histaminic. They have personal caregivers, usually family members,
polyvalent action, expressed at the and, if possible, of the wider community in
mesencephalic, hippocampal and cortical level providing support is of outmost importance.
[15-17]. Since the common use of antipsychotic drugs
Atypical antipsychotics cause antipsychotic and patient deinstitutionalization, families begun
action on positive symptoms (hallucinations, to provide some of the functions and care that
delusional ideas, disorganized language, were formerly addressed only by psychiatric
catatonic or flagrantly disorganized behavior) institutions
and negative (affective flattening, anhedonia, The problem is that family caregivers provide
alogy, avolition, social withdrawal) [15]. considerable support to their ill relative and in
Atypical antipsychotics are [16,17]: turn experience significant burden. The negative
Clozapine, Olanzapine, Quetiapine, Risperidone, effects of persons with a serious mental illness
Ziprasidone, Amisulprid, Sertindol, on their family members have been explored
Paliperidone, Aripiprazole The drugs that have since the 1950s, and the term “caregiver burden”
depot formulas, as long acting injections (LAI) began to be used in the 1970s.
are: olanzapine, risperidone and aripiprazole.
Atypical antipsychotics have many Aim
advantages, for example, by comparison with Because caregivers of subjects with
neuroleptics they rarely give extrapyramidal schizophrenia experience significant burden in
phenomena or late dyskinesia, but they also have taking care of the patient, usually over a long
some important side effects that make patients period of time, we decided to analyze some of
stop therapy: the factors that can impact the perceived level of
- Extrapyramidal affect-low probability of stress.
inducing EPS
- Weight gain, which can trigger or worsen Material and method
diabetes
Our study group consisted of caregivers
- Non-specific ECG changes of ST, flattening
124 patients with schizophrenia, interviewed
or reversing the T wave
between January 2018 and July 2019. Patients
- Orthostatic hypotension, syncope,
were men and women over 18 years of age,
tachycardia
which were evaluated and monitored for a
- Hyperprolactinemia (antagonistic activity
period of 12-18 months.
against D2)
Inclusion criteria were:
- Sleepiness
• diagnosis of paranoid schizophrenia
- Anticholinergic symptoms (dry mouth
according to DSM IV TR criteria;
mucosa, blurred vision, constipation) [16-19].
• chronic evolution of over 3 years;
It is considered that therapeutic compliance
• complete data on the history and evolution
of patient with schizophrenia to antipsychotic
of the disease.
therapy is reduced, with more than 50% of
We analyzed demographic, clinical and other
patients not adhering to treatment (either they do
medical variables of patients and caregivers:
not collect their medication or they stop after
- demographic variables: sex; current age;
less than 30 days) [20].
age at the onset of the disease; educational level;
According to data from the specialized
marital status;
literature, we believe that the administration of
- clinical variables: type of onset; possible
depot formulas can improve the therapeutic
somatic or psychiatric comorbidities;
adherence of the schizophrenia patient, thus
- therapeutic compliance.
improving the quality of life. In the case of
We also evaluated caregivers’ burden, using
depot preparations, the administration being
the adapted Zarit interview [21].
done monthly or bi-monthly, the therapeutic
The data was provided by caregivers by
daily stress, both of the patient and of the
filling a questionnaire for their demographic
patients, is diminished, and professional
data and clinical data of patients, by using the
reintegration, where appropriate, is made
adapted Zarit scale with 22 questions and by
possible easier.
consulting the necessary medical documents for
Usually, traditional psychiatric hospitals,
the corresponding patients.
over time, are not effective in providing the type

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Current Health Sciences Journal Vol. 45, No. 3, 2019 July-September

The study was approved by the Ethics compare the mean values of numerical
Committee of the University of Medicine and parameters. If the ANOVA test result was
Pharmacy of Craiova. As the responders were statistically significant, we continued the
not psychiatric patients, the participation was analysis with “post hoc” tests, such as Fisher’s
voluntary and anonymous. LSD tests, to identify pairs of categories which
Statistical analysis was performed using have significant differences.
Microsoft Excel (Microsoft Corp., Redmond,
WA, USA), and IBM SPSS Statistics 20.0 (IBM Results
Corporation, Armonk, NY, USA) for processing First we analyzed the demographic data of
the data. To describe the numerical data used in caregivers and patients, as well as several
the present study, we used the classical clinical data of patients (Table 1).
statistical indicators: arithmetic mean and A series of statistical correlations were then
standard deviation. determined between the level of stress of
Because the study involved numerical caregivers and several demographic and clinical
comparisons between data that had Gaussian items related to the patients.
distributions, we used either Student's t test (for
2 groups) or ANOVA (for 3 or more groups) to
Table 1. Distributions of demographic and clinical variables within the study group

Patient gender Male-71 Female-53

Patient age 20-29 y.o.-4 30-39 y.o.-22 40-49 y.o.-48 50-59 y.o.-38 >60 y.o.-
12
Age of onset <20 y.o.-34 20-24 y.o.-30 25-29 y.o.-36 30-34 y.o.-16 >35 y.o.-8
Patient Education General High school-92 College-8
school-24
Patient Marital status Married-22 Divorced/Widowed-18 Single-24
Patient social Self-care-24 Dependent-82 Disturbing, aggressive
functioning behavior-18
Caregiver gender Male-7 Female-117
Caregiver age <50 y.o.-7 50-59 y.o.-43 60-69 y.o.-56 >70 y.o.-18
Caregiver Marital Married-94 Divorced/Widowed-22 Single-8
status
Clinical symptoms at Abnormal Perceptual disturbances Cognitive impairment-
onset affect-29 and bizarre ideas-72 23
Somatic Comorbidities Present-96 Absent-28
Therapeutic Good-56 Aided-38 Low-30
compliance
Medication type LAI-50 Oral-74

The distribution of Zarit scores was asymmetry towards lower values. This finding
between 21 and 63, with an average of allowed us to carry out the statistical analysis
42.36±8.64, showing a Gaussian distribution using parametric tests, such as Student’s t test
(Anderson-Darling p>0.05), with a slight and ANOVA.

57
60
46
No. of cases

50
40
30 16
20
5
10
0
20-30 30-40 40-50 50-60+
Zarit score
Fig.1. Distribution of Zarit scores

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Livia Mihaela Strunoiu et al. - Factors that Impact Caregivers of Patients with Schizophrenia

60

Mean value ± S.D.

50
43.68 40.59
40

30

20

10

0
Male Female
p test Student = 0.015 - S
Fig.2. Comparison of average Zarit score based on patients’ gender

Comparing the average Zarit scores of male patients reporting higher values than caregivers
and female patients (Fig.2.), we found a of female patients (p Student=0,015<0.05).
significant difference, caregivers of male

60
46.18 45.36
50
Mean value ± S.D.

44.63 42.37
40.25
40

30

20

10

0
20-29 30-39 40-49 50-59 >60
p ANOVA= 0.103

Fig.3. Comparison of average Zarit score based on patients’ age

While we encountered slightly higher statistically significant difference between the

average values for the Zarit scores of younger age decades ranging from 20 to over 60 years of
patients, the data in our study do not prove a age (Fig.3.).

60
47.36
Mean value ± S.D.

50
42.32 43.22
41.19 39.87
40

30

20

10

0
<20 20-24 25-29 30-34 >35
p ANOVA= 0.012

Fig.4. Comparison of average Zarit score based on age of onset

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It seems the age of onset has an impact on the with Fisher’s LSD post-hoc test, and we
present perceived burden, because we found a discovered the 20-24 age of onset to have a
significant value performing the ANOVA test, significantly greater average score than all the
p=0.012<0.05. Because we obtained a others age categories (Fig.4).
significant result, we continued the data analysis

60
43.61
Mean value ± S.D.

42.58
36.36
40

20

0
General school High school  College
p ANOVA= 0.049

Fig.5. Comparison of average Zarit score based on patients’ educational level

Caregivers of patients who managed to attain ANOVA=0.049), because of the very small
college education have lower scores than the numbers of patients that went to college, fact
other two categories, but the significance of this that induces a greater level of error. (Fig.5.)
result is just slightly below the 0.05 threshold (p

60
44.17 43.15
50
Mean value ± S.D.

37.86
40
30
20
10
0
Married Divorced or widowed Single
p ANOVA= 0.004

Fig.6. Comparison of average Zarit score based on patients’ marital status

As expected, the caregivers of patients that scores that the caregivers of single or
have better preserved social relationships and divorced/widowed patients, the result having a
are married report significantly lower burden 99% confidence level (p=0.004<0.01, Fig.6).

60
49.36
41.98
Mean value ± S.D.

38.41
40

20

0
Self-care Dependent Disturbing,
p ANOVA= 0.000
aggressive behavior

Fig.7. Comparison of average Zarit score based on patients’ social functioning level

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Analyzing the burden differences when behavior showing much greater levels of burden
grouping the patients based on their social than caregivers of dependent, but compliant
functioning, we found a highly significant result, patients, which, in turn, have greater scores than
p ANOVA<0.001 (Fig.7.), caregivers of patients patients that can take care of themselves, under
that exhibit often disturbing or aggressive caregiver‘s supervision.

70
Mean value ± S.D.

60
50 47.36
42.06
40
30
20
10
0
Male Female
p test Student = 0.061 - NS
Fig.8. Comparison of average Zarit score based on caregivers’ gender

Even if the difference between the average small fraction of caregivers, only 5.65%, are
Zarit scores of male and female caregivers male, which leads to a greater statistical margin
seems very big, 47.36 vs. 42.06, we could not of error (Fig.8).
prove statistical significance, because only a

60
45.77
50
Mean value ± S.D.

44.67 40.48 41.37

40
30
20
10
0
<50 50-59 60-69 >70
p ANOVA= 0.018

Fig.9. Comparison of average Zarit score based on caregivers’ age

We found that younger caregivers tend to Fisher’s LSD post-hoc test, we proved that both
have a greater level of stress and perceive a caregivers aged less than 50 years and between
heavier burden than older caregivers, the 50-59 years have significantly greater average
ANOVA test returning a significant result, scores than caregivers aged between 60-69 years
p=0.018<0.05. Continuing the analysis with or above 70 years (Fig.9).
60
44.54 46.36
50
Mean value ± S.D.

41.51
40
30
20
10
0
Married Divorced or widowed Single
p ANOVA= 0.036

Fig.10. Comparison of average Zarit score based on caregivers’ marital status

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Caregivers that are married have lower significant, with an ANOVA p=0.036<0.05,
burden scores than caregivers that are divorced, presumably because of support from the spouse
widowed or single, the result being statistically (Fig.10).

60
Mean value ± S.D. 42.28 42.87 40.86
40

20

0
Abnormal affect Perceptual Cognitive
disturbances and impairment
bizarre ideas
p ANOVA= 0.218

Fig.11. Comparison of average Zarit score based on clinical symptoms at onset

We found no significant differences among onset, the ANOVA test result being
the average Zarit scores of caregivers when p=0.218>0.05 (Fig.11).
grouping the patients based on their type of
60
50
Mean value ± S.D.

43.50
38.47
40
30
20
10
0
Present Absent
p test Student = 0.007 - S

Fig.12. Comparison of average Zarit score based on somatic comorbidities

Caregivers of schizophrenic patients that greater burden scores than the others, Student’s t
have somatic comorbidities (cardiovascular, test showing a significant result, p=0.007<0.001
metabolic, neurological etc.) have, on average, (Fig.12).

70
60
Mean value ± S.D.

45.24 49.41
50
36.63
40
30
20
10
0
Good Aided Low
p ANOVA= 0.000

Fig.13. Comparison of average Zarit score based on patients’ therapeutic compliance

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As expected, there is a highly significant is good, the overall score is much lower than if
difference (p ANOVA<0.001, Fig.13.) among the patient has to be persuaded to take the
the average scores recorded for caregivers of medication, and is almost 75% of the average
patients when grouping them based on their score if the patient has a very low therapeutic
therapeutic compliance. If patient’s compliance compliance.

60

50 44.32
Mean value ± S.D.

39.45
40

30

20

10

0
LAI Oral
p test Student = 0.009 - S

Fig.14. Comparison of average Zarit score based on type of main medication

Caregivers of patients that have LAI as main study females represented 94.35% of all
medication have lower Zarit scores than patients caregivers, of which the greater part were
that do not use such injections, Student t test mothers of the patients, and male caregivers for
showing a difference level of 99% confidence patients with schizophrenia seem to be the
(p=0.009<0.01, Fig.14). exception from the general rule.
Because of the small number of male
Discussions caregivers we were not able to prove statistically
The average Zarit score in our study was significant difference between the average Zarit
42.36±8.64, which shows moderate to high scores of male and female caregivers, despite the
burden. observed numerical difference, 47.36 versus
This value lies in-between other data in 42.06.
literature, an article in Turkey reporting an 57.26% of patients were male, with a male:
average of 54.76±16.58 [22], while a Spanish female ratio of 1.34, similar to globally reported
article reports 37.9±15.0 [23]. data[5], but lower than other studies concerned
Another research article, carried out in Chile with caregivers’ burden, the male percentage
on a slightly modified Zarit scale, with scores up varying from 76.1% [22], to 67% [23], and
to 110 instead of 88, describes an average 63.41% [24].
burden of 86.51±12.97, corresponding to intense Our findings suggest that the average Zarit
burden [24], and an Iranian work reports score for male patients is greater than the score
51.73±18.23 [25]. for female patients.
t might be appropriate to speculate that the Average age of caregivers is 61.17±13.47
average burden is related to socio-economic years of age, close to other data in literature
factors, depending on the income level of the (60.1±11.7 [23], 53.3±18.7 [25] or 58.8±15.33
country and other welfare facilities, and this is for female caregivers and 60.2±12.6 for male
why there are differences among the average caregivers [26]), while there are other studies
burden reported in various countries for reporting a significant lower mean caregiver
caregivers of schizophrenic patients. age, such as one based in Turkey, with an
While other articles report a percentage of average of 49.68±12.47 [22].
female caregivers ranging from 64.8% to Our finding suggest that a lower caregiver
76.38% [22-26], and it is estimated by the World age corresponds to a more intensely perceived
Federation of Mental Health that 80% of the burden, similar to another European study[23],
caregivers in the world are female [22], in our while other data suggests the opposite [22,24] or
no influence between the caregiver’s age and

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level of burden [25,26], in this case caregiving Conclusions

duration being a more important factor that Although schizophrenia mainly affects the
overshadows the age of the caregiver, or patients, directly, it indirectly affects their
assisting a younger patient [25], probably caregivers.
because caregivers do not know yet how to cope The study shows that providing care for a
with the situation or they feel that they do not permanently, chronically ill family member is
have control of it. very stressful.
75.81% of caregivers were married, 17.74% Several factors that influence the perceived
were widowed or divorced, and 6.45% were burden of the caregiver have been identified,
single, the percentage of married caregivers such as patient gender, age of onset, patient and
being higher than in other European studies caregiver marital status, patient level of
[23,26], on the account of a lower percentage of education and social functioning, caregiver age,
widowed/divorced caregivers. somatic comorbidities and therapeutic
The marital status of the caregiver impacts compliance of the patient.
the perceived burden, single persons showing a The caregivers of persons with schizophrenia
much higher Zarit score than married persons show a high level of burden because of the
(46.36 vs. 41.51). permanent attention needed by the patient,
More important, patients’ marital status and which affects negatively other life areas.
level of social functioning are factors that Therefore, healthcare services for
significantly influence the perceived level of schizophrenia patients should also take into
burden, caregivers of married patients and consideration aspects of wellbeing of caregivers.
patients that are capable of self-care under
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Corresponding Author: Mihail Cristian Pirlog, Department of Sociology,

University of Medicine and Pharmacy of Craiova, Romania, Petru Rares St. no.2, Craiova, Romania;
e-mail: [email protected]

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