Original Article ISSN: 1110-5925

Depressive Disorders Among Caregivers of Schizophrenic Patients in Relation To

Burden of Care and Perceived Stigma

Ashraf Mohamed Ali El-Tantawy1, Yasser Mohamed Raya2 and Al-Sayed Mohamed Kamal Zaki3

Department of Psychiatry, Faculty of Medicine, Suez Canal University, 2Departments of Psychiatry Faculty of Medicine, Al-
1

Qassim University and 3Al-Gassim Rehabilitation Center

ABSTRACT
Introduction: Schizophrenia is among the most burdensome and stigmatized illnesses worldwide. It is a
challenging task for caregivers especially in the current era of de-institutionalization that can cause
depressive disorders among caregivers.
Aim of the Study: To evaluate Depressive Disorders among caregivers of schizophrenic patients and its relationship
with burden of care and perceived stigma.
Subjects and Methods: Sixty primary caregivers of patients with schizophrenia, and 30 healthy non-caregivers as a control
group. Both groups were screened for depressive symptoms using the Center of Epidemiological
Studies for Depression Scale. Diagnosis of Depressive Disorders was made according to DSM-IV-TR
criteria. The Caregiver Strain Index and the Discrimination-Devaluation Scale were administered to
the caregivers.
Results: Depressive Disorders were higher among caregivers (18.33%) than control group (3.33%) with
(p ‹0.05). The most common Depressive Disorders among the caregivers group was adjustment
disorder with mixed anxiety and depressed mood (6.67%). Depressive Disorders were correlated
with burden of care and perceived stigma. Depressive symptoms were associated with increased
number of hours per week for providing care, older age of the caregiver and duration of care giving.
Conclusion: These results can be used to plan interventions to reduce caregiver stressors. Mental health services
must be directed to caregivers as well as patients of schizophrenia.

Key words: Schizophrenia, Caregivers, Depression, Burden, Stigma.

Current Psychiatry; Vol. 17, No. 3, 2010: 15-25

INTRODUCTION

Schizophrenia is a severe mental disorder, characterized

by fundamental disturbances in thinking, perception and mental and emotional toll of caregiving can be devastating
emotions. It is among the most burdensome illnesses and may lead to injury or illness of the caregiver3,23-26.
worldwide. In addition to the direct burden, there is
considerable burden on the relatives who care for the In developing countries, despite the apparent downfall
sufferers1-9. The presence of someone with schizophrenia in of traditional family structure, over 60% of patients with
the home, especially after deinstitutionalization, can result in long-term schizophrenia live with at least one significant
burden affect the work and social life of family members or other', i.e. primary caregiver27,28. Recent changes in family
the caregivers2, 8, 10-17. Higher burden seemed to be associated structures and rapid economic decline are threatening the
with the caregiver's age and number of hours spent weekly on support available to patients with chronic mental illness9,29.
caring for the ill relative18. Caregiver burden in mental illness Disregarding the level of development of a country;
can either be objective or subjective. Objective burdens are caregivers experience high levels of burden25,30. Strain
defined as readily verifiable behavioral phenomena, e.g. due to medical costs, missed work and patients’ economic
negative patient symptoms; caregivers’ lives disrupted in dependency are considerable and linked to both objective
terms of domestic routine, social activities and leisure, social and subjective burden for family of severe mental illnesses
isolation, financial difficulties and employment difficulties. adults31-39 and reported across many cultures37,40-46.
Subjective burdens comprise emotional strain on caregivers,
e.g. fear, sadness, anger, guilt, loss, stigma and rejection19-22. Around 25% of caregivers of schizophrenic patients, either
Caregiving are often variable, constant and ongoing for long living with or living apart of the patients, met General Health
periods and the role of the caregiver is stressful. The physical, Questionnaire criterion for having a mental disorder47.

Personal non-commercial use only. Current Psychiatry Copyright © 2010. All rights reserved.
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Current Psychiatry
Vol. 17, No. 3, July. 2010

Caregivers of the patients with psychiatric illnesses such as caregivers. In an effort to maximize and prolong caregiving
schizophrenia have significant high level of depression48-52, in the community, it becomes essential to understand the
even in the absence of a prior mood disorder16,17,50,53,54. The consequences of caregiving of patients with schizophrenia.
commonest variables related to depression among caregivers There are little data known about caregivers of schizophrenic
were gender, socio-economic status, marital status, family patients in Arab countries particularly KSA. The present
size, education, relationship with the patient and the burden study sought to collect qualitative as well as quantitative data
of care15,17,55,57. Mental health services should aim to assist from a sample of schizophrenic caregivers.
key caregivers of people with chronic schizophrenic disorder
to manage their stress and related mental disorders47,48. Early The present study was conducted on primary caregivers of
interventions by conducting routine assessments of the patients with schizophrenia living in the community. The
depression status of caregivers and their available social study aimed to assess:
support, thereby preventing or minimizing depression in
these caregivers16,52,55,57-66. Depressive disorders (DD) burden of care and perceived
stigma among the primary caregivers of patients with
The stigma attached to mental illness is an issue of great schizophrenia.
concern to patients and their families. Obviously, stigma can
be a major obstacle to recovery and can limit opportunities Relationship between DD with burden of care and perceived
of work and social functioning of patients and family stigma among the primary caregivers of patients with
members across the world62,67-69. However, individuals with schizophrenia.
schizophrenia are not the only ones to be stigmatized. The
stigma is also conferred upon relatives, close friends and SUBJECTS AND METHODS
all those who come into close contact with the mentally
ill, including mental health professionals65,70-76. Stigma was Participants were 60 primary caregivers, regularly
unaffected by patient background characteristics62,77-79 and accompanying patients diagnosed as having schizophrenia
that perceived stigma is associated with reports of depressive as per the DSM-IV-TR criteria86, who attend the follow-up
symptoms65,80,81. Reducing isolation and stigmatization is outpatient clinics of Buraydah Mental Health Hospital, Al-
very important for reducing depression among families of Qassim, KSA and 30 normal non-caregivers as control. Those
schizophrenic patients51. Stigma towards relatives must be who did not participate almost invariably cited geographical
taken into account when planning for intervention by mental distance from the hospital.
health professionals68.
The primary caregivers were recruited according to the
The caregiver's burden seems to be independent of the following inclusion and exclusion criteria:
patient's diagnosis, but other factors contribute to the
perceived burden, many of which are on the caregiver's Inclusion criteria: A caregiver must be:
part18. Unless caregivers of patients with serious mental
illness are resourceful, they may experience considerable 1. 18 years old or above.
burden, stigma, depressive thoughts and poor quality of
life62,65,82,83. The extended family provides care for these 2. Taking care of a patient who is 18 years old or above
patients in the face of poor mental health facilities84. As there with the diagnosis of Schizophrenia as per the DSM-IV-
is a lack of reliable cost information about the family burden TR criteria.
of care specific to schizophrenia, there is an urgent need to
develop reliable approaches that can generate data that can 3. Taking care of a patient who is on medication and on
inform in policy making and organization of services8. All regular follow up in outpatient department for the past
caregivers may benefit from psychoeducation and family 6 months.
interventions usually planned for those caring for relatives
with schizophrenia18. Comprehensive multidisciplinary 4. Immediate family relative (Parent, spouse, sibling,
care of chronic schizophrenia patients is needed, care that brother or sister), non immediate family relative (Other
supports the needs and improves the psychiatric symptoms relative) or non-relative.
of the patients, helps to decrease the caregiver burden level
and facilitates family participation in treatment22. Helping 5. Primary caregiver as defined by an adult relative living
families of schizophrenics to maintain and enhance a with a patient, in the same environment, for at least
supportive social network may represent a useful means to 12 months and was involved directly in giving care to
reduce family burden in85. the patient and most supportive either emotionally or
financially, i.e. felt most responsible for the patient87,88.
Although a sizable body of literature is focusing on
caregivers of schizophrenia, studies that examine depressive Exclusion criteria
disorders according to ICD-10 criteria, as far as we know, are
few. Also, the continuing trend toward deinstitutionalization The caregiver will be excluded from the study in the
of schizophrenic patients will lead to more burden on the following situations:

16
 Depressive Disorders Among Caregivers of Schizophrenic Patients in Relation To Burden of Care and Perceived Stigma
Ashraf El-Tantawy et al.

1. If the patient has a diagnosis other than schizophrenia or confirm the diagnosis and the DSM-IV-TR criteria for
a comorbid diagnosis. depressive disorders (DD) was applied for diagnosis
2. If the patient was admitted to the inpatient departments among primary caregivers and control group86.
during the past 6 months.
3. If the patient was not on medications. 5. The Caregiver Strain Index (CSI): It is a brief, easily
4. If the caregiver is less than 18 years old. administered tool that can be used to quickly to identify
5. If the caregiver is not living with the patient for at least families with potential caregiving concerns. It is a
12 months. 13-question tool that measures strain related to care
6. If the caregiver is not involving directly in giving care. provision. There is at least one item for each of the
7. If the caregiver has a history of psychiatric disorder following major domains: Employment, Financial,
before being a caregiver. Physical, Social and Time. Positive responses to seven or
more items on the index indicate a greater level of strain
The normal non-caregivers were recruited from persons and a need for more in-depth assessment to facilitate
attending the hospital for other purposes than a patient care appropriate intervention. This instrument is appropriate
such as gun license. The normal non-caregivers must be 18 and can be used to assess individuals of any age who
years old or above. They must have no history of psychiatric have assumed the role of caregiver for an adult94.
disorders or have taking care of a schizophrenic patient or Internal consistency reliability is high (alpha=0.86) and
other chronic serious illness either physical or mental illness. construct validity is supported by correlations with the
physical and emotional health of the caregiver and with
Data collection: Over a period of 3 months, caregivers subjective views of the caregiving situation95. Various
who satisfied the criteria were interviewed after obtaining domains were identified that should be addressed in a
their written informed consent. The data were recorded and comprehensive assessment of the caregiving process96.
further aspects were studied as described below. The patient's cognitive status and problematic behaviors
should be assessed, as well as the caregiver's perception
Assessment tools: of role overload or deprivation in key relationships,
goals or activities. Family conflict, work role-caregiving
1. Demographic variables: were assessed through a written conflict and caregiver social support are also important
questionnaire including date of birth, sex, relationship variables in the overall caregiving experience.
to the patient, number of years of education completed,
marital status, number of months of caregiving and 6. Discrimination- Devaluation Scale (DDS):
number of hours per week providing care.
2. The Center for Epidemiological Studies-Depression Discrimination-Devaluation Scale (DDS), is a combination
Scale (CES-D): of the Patient Devaluation and Stigma Scale (PDSS), (8
items) and Family Devaluation and Stigma Scale (FDSS), (7
Depressive symptoms were assessed using the shortened items)97. DDS is a 15-item measure rating caregivers' views
version of the Center for Epidemiological Studies Depression about most people's acceptance of mental illness. A 15-item
(CES-D) scale. The original scale was designed to measure Likert scale (rating of statements such as ‘Most people look
the current level of depressive symptoms in the general down on families that have a member who is mentally ill’).
population89 (Cronbach’s α = 0.90). Whereas a formal All statements were rated on a 4-point scale with anchors
diagnosis for depression requires a clinical examination, the ranging from "agree strongly" to "disagree strongly". A sum
self-reported CES-D emphasizes subjective and affective of the 15 items yields a total stigma score ranging from (0
elements of depressive symptoms90. The shortened version of – 60); the PDSS score from (0 – 32) and the FDSS score
the CES-D used included 10 out of the 20 original items. The from (0 – 28), with higher scores indicating greater stigma,
response categories are "none or almost none of the time," (Cronbach’s α = 0.80)62.
"some of the time," "most of the time," and "all or almost all
of the time," coded 0 through 3, respectively. An overall score Study Procedure:
was obtained by adding the 10 items, producing a scale that
ranges from 0 (least depressed) to 30 (most depressed)91,92. Every primary caregiver, regularly accompanying patients
Score is the sum of the 10 item weights. If more than 2 items diagnosed as having schizophrenia as per the DSM-IV-
are missing, do not score the scale. A score of 10 or greater is TR criteria and on regular follow up in outpatient clinics
considered depressed93. of Buraydah Mental Health Hospital, Al-Qassim, KSA for
the past 6 months and on medication and 30 normal non-
3. Structured Clinical Interview for the Diagnostic and caregivers as control, were asked to give written consent
Statistical Manual of Mental Disorders, 4th edition to participate in the study. The primary caregivers were
(SCID-I; DSM-IV): All persons who got high score on selected according to the inclusion and exclusion criteria.
CES-D were assessed using the mood module of the The primary caregiver group and the control group were
SCID-I86. screened for depressive symptoms using the CES-D. Persons
4. Diagnostic and Statistical Manual of Mental Disorders, from both groups who had high score in the CES-D were
4th Edition, Text Revised (DSM IV TR): The DSM-IV- interviewed by the mood module of the SCID-I and DD were
TR criteria for schizophrenia was applied to patients to diagnosed according to the DSM-IV-TR criteria for mood
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Current Psychiatry
Vol. 17, No. 3, July. 2010

disorders. The Caregiver Strain Index and The Devaluation PDSS and 8.28±6.46 for FDSS with total score of 21.00±14.36
of Consumer Families Scale were applied to the caregivers in DDS. Most of the primary caregivers were living in the same
to assess the burden of care and the perceived stigma. home with the patient (86.67%), with the mean duration of care
giving in months (45.18±24.07) and number of hours per week
Statistical analysis: for providing care (29.75±8.99).
Table 2: Clinical Characteristics of Caregivers and Control
Demographic characteristics of the caregivers and the control
Groups.
group were compared using chi-square tests for categorical
Caregivers Control
data and t tests for continuous data. Chi-square with Yates’s Characteristics Group Group
correction, Fisher’s exact, Spearman’s rank order correlation (n= 60) (n= 30)
and Bonferroni correction were applied where appropriate. The CES-D 10 Score (Mean±SD) 7.68 ± 5.2** 2.63 ± 2.9
The Statistical Package for the Social Sciences98, was used Depressive Disorders (n and %) 11 (18.33 )* 1 (3.33 )
to conduct analyses. The CSI Score (Mean ± SD) 6.72 ± 2.7 NA
The DDS Score (Mean ± SD) 21.00 ± 14.36 NA
RESULTS The PDSS Score (Mean ± SD) 12.38 ± 7.62 NA

The FDSS Score (Mean ± SD) 8.28 ± 6.46 NA

There was no difference regarding sociodemographic
characteristics of both caregivers and control groups (Table 1). Living In The Same Home (n and %) 52 (86.67) NA

Male gender and married persons predominate female gender Duration of Care Giving In Months
45.18 ± 24.07 NA
and non-married persons in both groups with higher significance (Mean ± SD)

difference among the caregivers group (p ‹0.01). Higher Number of Hours/Week for
29.75 ± 8.99 NA
education (63.33%) and non-employed persons (66.67%) were providing Care (Mean ± SD)

significantly higher than low education (36.67%) and employed * Means p value ‹0.05, ** means p value ‹0.01, NA means Not Applicable.
CES-D 10= Center for Epidemiologic Studies Short Depression Scale. CSI= Care Strain Index.
persons (33.33%) among the caregivers group (p ‹0.05). Most DDS= Discrimination-Devaluation Scale, PDSS= Patient Devaluation and Stigma Scale
of the caregivers group was an immediate family relative (PDSS) and
FDSS= Family Devaluation and Stigma Scale.
(93.33%) with (p ‹0.01).
Applying the DSM-IV-TR criteria for persons who had score
Table 1: Demographic Characteristics of Caregivers and Control 10 or greater in the CES-D Scale showed that DD were higher
Groups. among caregivers (18.33%) than control group (3.33%) with (p
Caregivers Control ‹0.05) (Table 3). The most common DD among the caregivers
Characteristics Group Group group are adjustment disorder with mixed anxiety and depressed
(n= 60) (n= 30)
mood (6.67%) then adjustment disorder with depressed mood
Sex (n and %) (5.00%), followed by Dysthymic disorder (3.33%) and lastly
Male 45 (75.00)** 21 (70.00)* the major depressive disorder; single episode and recurrent
Female 15 (25.00) 9 (30.00)
Age (Mean ± SD, years) 39.2 ± 12.2 36.4 ± 9.5 (1.67%) for both disorders. Five percent of caregivers, who
Marital Status (n and %) had score 10 or greater in the CES-D Scale, have adjustment
Married 43 (71.67)** 23 (76.67)* disorder with anxiety.
Not Married 17 (28.33) 7 (23.33)
Education (n and %)
‹ 12 years education 38 (63.33)* 19 (63.33) DSM-IV-TR Depressive Disorders Among Caregivers
Table 3:
› 12 years education 22 (36.67) 11 (36.67) and Control Groups.
Occupation (n and %) Caregivers Control
Employed 20 (33.33) 15 (50.00) Depressive Disorders (n and %) Group Group
Non employed 40 (66.67)* 15 (50.00) (n= 60) (n= 30)
Socioeconomic Status (n and %) 296.x Major Depressive Disorder (MDD) 2 (3.33) 0 (0.00)
Low 31 (51.67) 16 (53.33) 296.2 MDD; Single Episode 1 (1.67) 0 (0.00)
Moderate 25 (41.67) 11 (36.67) 296.3 MDD; Recurrent 1 (1.67) 0 (0.00)
High 4 (6.67) 3 (10.00) 300.4 Dysthymic Disorder (DD) 2 (3.33) 1 (0.00)
309.x Adjustment Disorder (AD) 10 (16.67) 0 (0.00)
Relationship To The Patient 309.0 AD with Depressed Mood 3 (5.00) 0 (0.00)
Immediate Family Relative 56 (93.33)** NA 309.28 AD with Mixed Anxiety and Depressed Mood 4 (6.67) 0 (0.00)
309.24 AD with Anxiety 3 (5.00) 0 (0.00)
Non Immediate Family Relative 3 (5.00) NA
Non Relative 1 (1.67) NA
Total Depressive Disorders 11 (18.33)* 1 (3.33)
* Means p value ‹0.05, ** means p value ‹0.01, NA means Not Applicable.
* Means p value ‹0.05.

Caregivers group had higher score regarding the CES-D 10 Table 4 shows that depressive symptoms were high significant
scale (7.68±5.2) than the control group (2.63±2.9) with (p ‹0.01) among caregivers than control regarding feeling of fears
(Table 2). Also, DD according to DSM-IV-TR criteria were (65.00% vs. 6.67%), depressed mood (55.00% vs. 6.67%) and
higher in caregivers group (18.33%) than control group (3.33%) unhappiness (48.33% vs. 3.33%), with (p ‹0.01). Restless sleep
with (p ‹0.05). The burden of care score was (6.72±2.7) among (78.33% vs. 20.00%), decrease interest (35.00% vs. 10.00%),
the caregivers group according to the CSI. Caregivers group difficulty in cognition (20.00% vs. 3.33%), hopelessness
had a high level of stigma and discrimination; 12.38±7.62 for (18.33% vs. 0.00%) and feeling of loneliness (15.00% vs.

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 Depressive Disorders Among Caregivers of Schizophrenic Patients in Relation To Burden of Care and Perceived Stigma
Ashraf El-Tantawy et al.

0.00%), with (p ‹0.05). There were no significant difference were (40.82±13.59 vs. 16.55±10.24 with p ‹0.01). Depressed
regarding fatigue and psychomotor retardation. Caregivers caregivers had significantly higher scores in both PDSS and
group had higher score in total symptomatology of depression FDSS (22.36±7.16 vs. 10.14±5.72 with p ‹0.01 and 16.64±5.54
with mean score (7.68±5.2 vs. 2.63±2.9; p ‹0.01). About 23.33% vs. 6.41±5.02 with p ‹0.01), respectively.
of the caregivers group versus 3.33% of the control group were
considered positive for the CES-D 10 scale as they got 10 or Table 6: Stigma Among Caregivers In Relation to DSM-IV-TR
greater score with (p ‹0.05). Depression.
Table 4: Depressive Symptoms Among Caregivers According Caregivers Group Caregivers Group
To The CES-D 10. Stigma Subscales with Depression without Depression
(n= 11) (n= 49)
Depressive Symptoms Caregivers Group Control Group
(n and %) (n= 60) (n= 30) The PDSS Score
22.36±7.16**
(Mean ± SD) 10.14±5.72
Decrease Interest 21 (35.00)* 3 (10.00) The FDSS Score 6.41±5.02
Difficulty in Cognition 12 (20.00)* 0 (3.33) 16.64±5.54**
(Mean ± SD)
Depressed Mood 33 (55.00)** 0 (6.67)
Fatigue 7 (11.67) 0 (3.33) The DDS Score
40.82±13.59** 16.55±10.24
Hopelessness 11 (18.33)* 0 (0.00) (Mean ± SD)
Feeling of Fears 39 (65.00)** 0 (6.67)
The DDS Results
Restless Sleep 47 (78.33)* 6 (20.00) 11 (100.00)* 36 (73.47)
(n and %)
Unhappiness 29 (48.33)** 0 (3.33)
Feeling of Loneliness 9 (15.00)* 0 (0.00) * Means p value ‹0.05, ** means p value ‹0.01, DDS= Discrimination-
Psychomotor Retardation 2 (3.33) 0 (0.00) Devaluation Scale, PDSS= Patient Devaluation and Stigma Scale and FDSS=
Family Devaluation and Stigma Scale.
The CES-D 10 Score
7.68±5.2** 2.63±2.9
(Mean ± SD)
Regarding factors associated with depressive symptoms among
The CES-D 10 Results caregivers using Spearman correlation coefficient for measuring
14 (23.33)* 1 (3.33)
(n and %)
the rank of order for factors (Table 7), depressive symptoms
* Means p value ‹0.05, ** means p value ‹0.01. were associated with increased number of hours per week for
CES-D 10= Center for Epidemiologic Studies Short Depression Scale.
providing care (0.255), older age of the caregiver (0.324) and
Comparing caregivers with DSM-IV-TR criteria for depression duration of care giving in months (0.461), then scores in CSI
and caregivers without DSM-IV-TR criteria for depression (0.604), PDSS (0.630), DDS (0.669) and FDSS (0.695).
regarding their burden of care showed that all depressed Table 7: Factors Correlated with Depressive Symptoms Among
caregivers had burden of care (100.00 vs. 32.65% with p ‹0.01)
The Caregivers.
(Table 5),. Depressed caregivers had higher scores in the CSI
Scale (10.09±1.7 vs. 5.96±2.3 with p ‹0.01). Physical burden Rank of Order for Factors
CES-D 10 Score
was the most significant common burden among the depressed Correlation Coefficient
caregivers vs. Non-depressed caregivers (100.00% vs. 30.61% 1- Number of Hours/Week for
0.255
with p ‹0.01), followed by social burden (100.00% vs. 91.84% providing Care
with p ‹0.05) and time burden (100.00% vs. 85.29% with p 2- Age 0.324
‹0.05). The least burden was the financial burden (18.18% 3- Duration of Care Giving In
0.461
vs. 2.04% with p ‹0.05) but the employment burden was not Months
significant between both groups. 4- CSI Score 0.604
Table 5: Burden of Care Among Caregivers In Relation to 5- PDSS Score 0.630
DSM-IV-TR Depression. 6- DDS Score 0.669
Caregivers Caregivers
7- FDSS Score 0.695
Group with Group without
Type of Burden
Depression Depression CES-D 10= Center for Epidemiologic Studies Short Depression Scale. CSI= Care
(n= 11) (n= 49) Strain Index.
DDS= Discrimination-Devaluation Scale, PDSS= Patient Devaluation and Stigma
Employment Burden (n and %) 6 (54.55) 36 (77.55) Scale (PDSS) and
Financial Burden (n and %) 2 (18.18)* 1 (2.04) FDSS= Family Devaluation and Stigma Scale.
Physical Burden (n and %) 11 (100.00)** 15 (30.61)
Social Burden (n and %) 11 (100.00)* 45 (91.84)
Time Burden (n and %) 11 (100.00)* 42 (85.29) DISCUSSION
The CSI Score (Mean ± SD) 10.09 ± 1.7** 5.96 ± 2.3
Regarding sociodemographic characteristics of the studied
The CSI Results (n and %) 11 (100.00)** 16 (32.65)
groups, male gender and married persons predominate female
* Means p value ‹0.05, ** means p value ‹0.01 and CSI= Care Strain Index. gender and non-married persons with higher significance
difference among the caregivers. These findings are due to
Comparing depressed caregivers and non-depressed cultural factors as in Saudi Arabia, the male and married
caregivers regarding stigma and discrimination due to mental person is the responsible person either outside the home or
illness (Table 6), all depressed caregivers perceived stigma inside the family. The females in KSA, especially in Qassim
(100.00% vs. 36.47% with p ‹0.05) and their scores in DDS area, cannot drive or dealing with foreigner males in any

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Current Psychiatry
Vol. 17, No. 3, July. 2010

situation so the cultural factors limits their roles in caring of caregivers of schizophrenics can be explained primarily due
the family members. The highly educated and non-employed to many burdens; financial burden, role burden, physical
persons were significantly higher than low education and burden, time burden and emotional burden. A result
employed persons among the caregivers. Higher educated consistent with many previous studies15,52,54,57. Also, stigma
person is the person who is the most knowledgeable regarding attached to schizophrenia plays an important part in the high
the schizophrenia and the importance of caring it. Also, high prevalence of DD among caregivers. This result is consistent
rate of the non-employed persons among caregivers can be with some studies65,80,81.
explained as a result of caregiving and associated stigma;
they do not search for work, they do not find work or they We found that DD were higher among caregivers than
may lose their work. Most of the caregivers in our study were control group. The most common DD among the caregivers
immediate family relatives as a primary supportive group for group are adjustment disorder with mixed anxiety and
those patients who are not insighted. depressed mood then adjustment disorder with depressed
mood and followed by Dysthymic disorder. These findings
The primary purpose of this study was to detect the can be explained that most of the caregivers, who have DD,
prevalence of DD among primary caregivers of patients have non major DD in which psychosocial stressors play an
with schizophrenia living in the community. The second important part in their etiology and we claim that burden due
purpose of the study was to describe the association between to care and perceived stigma towards the caregivers have
DD and other variables; the burden of care, perceived an essential role in their etiology and maintenance. Results
stigma and quality of life as consequences of caregiving are consistent with most studies done on the same group of
for schizophrenic patients. The method of subject selection population15, 30, 52, 54, 57, 65, 80, 81. So, reducing stress, isolation
in this study limits the sample of primary caregivers who and stigmatization is very important for reducing depression
have a long-term relationship with the patients. Thus, those among caregivers of schizophrenic patients48,51 and must be
caregivers are the most persons who have burden and taken into account when planning for intervention by mental
perceive stigma regarding their caregiving and the most health professionals68. Better liaison is required between
susceptible persons to be affected either psychologically psychological/ medical professionals and caregivers to
or physically. Among the caregiver characteristics, higher see whether they are psychologically helping caregivers
levels of burden, perceived stigma and poor quality of of schizophrenic patients to know about their severity of
life were associated with depressive symptoms. Previous depression and to treat it16. Lastly, the major DD; single
research on caregivers of persons with schizophrenia, as far episode and recurrent was 1.67% for both disorders. A
as we know, has been minimal and has primarily focused on result that is not higher than major DD in general population
how the caregiver is affected by the patient clinical profile57. and may be due to genetic or other biological factors but
burden and stigma may affect its severity or course. Major
Regarding symptoms of depression among caregivers DD among the caregivers may also affects the ability of the
of schizophrenia, 23.33% of the caregivers group versus caregiver to care of the patient and leads to deterioration of
3.33% of the control group were considered positive for the patient condition.
the CES-D 10 scale as they got 10 or greater score, with
mean score in total symptomatology of depression 7.68 ± Comparing the caregivers with DSM-IV-TR criteria for
5.2 vs. 2.63 ± 2.9. The results confirmed that caregivers depression and caregivers without depression regarding
have symptoms of depression significantly higher than the their burden of care, we found that all depressed caregivers
control group. These findings are consistent with most of the had burden of care and had higher scores in the CSI Scale
recent researches15-17,48-50,52-54,57. We found high significance than the caregivers without depression. We are in agreement
difference among the caregivers than the control regarding with all previous studies that concluded that depression
feeling of fears, depressed mood, unhappiness, restless sleep, among caregivers of schizophrenics is due to burden of
decreased interest, difficulty in cognition, hopelessness and care15-17,49-54,57. So, we confirmed that burden of caregiving
feeling of loneliness. There were no significant difference for schizophrenic leads to depressive disorders. We are in
regarding fatigue and psychomotor retardation. These finding agreement of previous studies that concluded that supporting
can help the psychiatric team in assessment and detection someone with schizophrenia is a difficult and life long
of depressive disorders among caregivers. So, psychiatric effort that can be very stressful as reported across many
team are in a pivotal position to provide early interventions culture14,16,37,40-46. Our study found that physical burden was
by conducting routine assessments of the depression status the most significant common burden among the depressed
of caregivers and their available social support, thereby caregivers vs. non-depressed caregivers. This result is
preventing or minimizing depression in these caregivers52. consistent with most of the previous studies that emphasized
the objective burden on the caregivers due to caregiving
The results confirmed that caregivers have DD significantly and role burden2,8,10-12,15,17. We found that social burden and
higher than control group. About 18.33% of the primary time burden are significantly higher among the depressed
caregivers vs. 3.33% of the control group were confirmed caregivers than the non-depressed caregivers. A result that
to have depressive disorders according to DSM-IV-TR is in agreement with some studies16,19,21,25. The least burden
criteria. These findings are consistent with most of the recent associated with depression was the financial burden. This
researches15-17,48-50,52-54,57. High prevalence of DD among finding is inconsistent with other studies that magnified the

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 Depressive Disorders Among Caregivers of Schizophrenic Patients in Relation To Burden of Care and Perceived Stigma
Ashraf El-Tantawy et al.

financial burden as a key burden leads to other burdens14,16. stigma erodes the morale of the caregivers who help care for
This disagreement may be due to that in Saudi Arabia, the them and leads to depression57,65. So, dealing with current
government supports the schizophrenics and their families problem of caregivers DD, we have to deal with all factors
in many financial aspects and covers all management costs. associated with depression; caregiving needs, burden of care
We found that the employment burden was not significant and stigma towards the patient and his caregivers. Dealing
between both groups. A result that is not in agreement with with these factors and depression among the caregivers will
many studies that magnified unemployment as a burden for improve the caregivers' conditions which has greater effects
caregivers33,34,36,37,39. This may be due to the family structure on the clinical profile of schizophrenic patients.
and dynamics in Saudi Arabia and due to some cultural
factors that make unemployment is not a significant burden There are important clinical implications that can be drawn
as the government supports the unemployed persons and from the findings of the present study. Clinicians should be
also the citizens of low income. aware of the high rates of DD in caregivers of people with
Schizophrenia. In the era of community mental health, it
Our finding that greater perceptions of stigma towards would help develop community-specific programs to target
caregivers were associated with significantly higher levels caregivers for psychosocial intervention which would teach
of depressive symptoms suggests that in addition to posing them to focus on the positive feelings they experience in
a barrier to the recovery of people with schizophrenia, association with the caregiving role99. This could diminish
stigma erodes the morale of the caregivers who help care the burden of illness felt by them and prevent role overload.
for them57,65. The finding that social support and avoidance The current study has a number of limitations. First, the
coping together largely explained the association between analyses are cross-sectional. Second, despite the small
stigma and depression offers an explanation for the sample size in our study, the differences in psychological
depressive symptoms commonly reported and was explained morbidity between caregivers and controls were still evident.
by57,65. Because social support is a well-established buffer The findings can serve as a reference for mental health
against recurrence of depression, withdrawal from potential professionals as they develop mental health care program for
supporters as an adaptation to stigmatization illustrates the patients and also for caregivers.
double jeopardy confronting caregivers of patients with
mental illness. We are in agreement with other studies like,
who found that stigma was significantly related to caregivers' CONCLUSION
depressive symptoms independently of other variables but
because our study uses cross-sectional data we cannot make Caregivers for schizophrenic patients reported high levels of
causal inferences. However, recurrence of depression has depressive symptoms; the majority of these caregivers who
been linked to psychosocial stressors such as caregiving have depressive symptoms met the established DSM-IV-TR
strain65 and contending with social rejection and attendant criteria for clinical DD. The strongest and most consistent
feelings of shame and embarrassment constitutes a major predictors of DD were caregiver burden, perceived stigma
caregiving strain57,65,82. Results suggest that caregivers’ due to mental disorder and poor quality of life. Depressive
perceptions of stigma may negatively affect their mental symptoms were associated with increased number of hours
health by reducing their coping effectiveness57,65. per week for providing care, older age of the caregiver and
duration of care giving. These results can be used to plan
Our results regarding factors that are associated with interventions to reduce caregiver stressors. Mental health
depressive symptoms are consistent with most of the services must be directed to the caregivers as well as the
previous studies. Depressive symptoms were associated patients of schizophrenia.
with increased number of hours per week for providing
care, older age of the caregiver, duration of care giving ACKNOWLEDGEMENT
in months18. These results can be explained in the light of
increased burden of care either objective or subjective and This study was supported by Al-Gassim University, KSA. We
their effect on the person who care for a chronic and serious appreciate the help and cooperation done by The Ministry of
mental disorder. Association of poor quality of life (SF 36 Health, Buraydah Mental Health Hospital, Al-Gassim, KSA.
score) with depressive symptoms among the caregivers is
in agreement with many studies30,65,78. This result can be
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Corresponding Author:

Ashraf Mohamed Ali El-Tantawy

Assistant Professor of Psychiatry
Faculty of Medicine, Suez Canal University, Egypt.
E-mail: [email protected]

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