ORIGINAL PAPER

Rakesh K. Chadda Æ Tej B. Singh Æ Kalyan K. Ganguly

Caregiver burden and coping

A prospective study of relationship between burden and coping in caregivers

of patients with schizophrenia and bipolar affective disorder

Received: 27 January 2007 / Accepted: 20 July 2007 / Published online: 13 August 2007

j Abstract Introduction: Caregivers of patients ofschizophrenia and bipolar affective disorder (BAD)experience considerable burden while caring theirpatients. They develop different coping strategies todeal with this burden. Longitudinal studies are re-quired to assess the relationship between caregiverburden and coping. Aim: The present study wasconducted to assess relationship between burden andcoping in caregivers of clinically stable patients withschizophrenia and BAD. Method: One hundred pa-tients each of schizophrenia and BAD attending apsychiatric outpatient setting and their caregiverswere followed up for a period of 6 months. Burdenand coping strategies were assessed in the caregiversat baseline, and after 3 and 6 months using the Bur-den Assessment Schedule (BAS) and Ways of CopingChecklist - Hindi Adaptation (WCC - HA). Results:Burden remained stable over 6 months and wascomparable in the two groups of caregivers. Care-givers from both the groups were found to use pro-blem focused coping strategies more often than seeksocial support and avoidance strategies. Scores onavoidance type of coping showed a positive correla-tion with the total burden scores and a number ofburden factors. Conclusion: Caregivers of patients ofschizophrenia and BAD face similar levels of burden

and use similar types of coping methods to deal withit. Relationship between caregiver burden and copingis quite complex.

j Key words burden – coping – schizophrenia –bipolar disorder – India

Introduction

Patients suffering from schizophrenia and bipolaraffective disorder (BAD) impose considerable burdenon their caregivers [4, 6, 14, 23]. The burden includesmultiple responsibilities such as financial costs,physical care of the patient and compromises on thepersonal freedom and leisure activities [22, 25, 27, 31],and has been reported to affect the course of illness[24, 26, 28]. Severity of illness and symptom charac-teristics are important predictors of burden [28, 33,34], with disorganized behaviour [34] being especiallyassociated with higher levels of burden.

The caregivers develop different kinds of copingstrategies to deal with the burden which includefinding a reasonable solution, looking for supportfrom friends or other near ones, or trying to avoid thesituation by indulging in activities like smoking orsubstance abuse [13, 20, 30]. Caregivers experiencehigher levels of burden when they have limited copingresources [1, 10]. Reduction in the perceived burdenhas been reported in the caregivers who adapt lessemotion focused coping strategies [13].

The earlier studies on caregiver burden and copingwere cross sectional in nature [3, 12, 14, 20, 29]. Thecross sectional studies provide limited informationabout the influence of various social and clinicalfactors on burden, and whether burden remains stableover the course of illness or changes as per the cir-cumstances [13, 28]. Caregiver burden has been re-ported to be closely interconnected with the course of

Prof. R.K. Chadda (&)All India Institute of Medical SciencesAnsari NagarNew Delhi 110029, IndiaTel.: +91-11/2659-3236 or -3245Fax: +91-11/2658-9787 or -8663E-Mail: drrakeshchadda@hotmail.com

T.B. SinghDept. of Clinical PsychologyInstitute of Human Behaviour & Allied SciencesDelhi, India

K.K. GangulyIndian Council of Medical ResearchNew Delhi, India

Soc Psychiatry Psychiatr Epidemiol (2007) 42:923–930 DOI 10.1007/s00127-007-0242-8SP

PE

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the patient’s illness [8, 10] and is likely to improve, asthe patient responds to treatment. Since burden islikely to change over the course of illness [8, 10],longitudinal studies are needed to understand theburden characteristics and factors affecting it. Simi-larly, comprehensive longitudinal assessment of thecoping strategies used by the caregivers is required sothat any maladaptive methods can be identified anddealt with appropriate interventions.

Most of the initial studies on burden of psychiatricillnesses were in schizophrenia [6, 31]. Later studiesconducted on caregivers of BAD patients have re-ported similar level of caregiver burden [11, 23].There have been only a few studies, which havecompared burden and coping in the caregivers ofpatients with schizophrenia and BAD [2, 3, 19, 29].The earlier studies reported similar pattern of burdenin caregivers of patients with schizophrenia and BAD[3], though those caring for schizophrenia were foundto perceive higher burden as compared to that in BADgroup [3, 29]. Some differences were also observed inthe coping strategies used by the caregivers from thetwo groups of patients [2, 19]. Caregivers from theBAD group use the problem focused strategies moreoften, whereas schizophrenia caregivers have beenreported to resort more often to the emotion focused(or maladaptive) strategies [2]. The same group ofauthors in a later study reported more frequent use ofcoercive coping and avoidant behaviour strategies(i.e. smoking, drinking, taking pills etc.) by caregiversof patients of schizophrenia [19].

There is a lack of longitudinal comparative studieson burden and coping in schizophrenia and BAD, thetwo most disabling psychiatric disorders besidesdepression. Longitudinal and comparative studiesmay help in understanding the complex relationshipbetween the caregiver burden and coping.

The present study assessed burden and copingstrategies in a group of caregivers of patients withschizophrenia and BAD in a prospective design andanalyzed the relationship between various compo-nents of the caregiver burden and coping strategies.

Material and methods

j Sample

The study was conducted from November 2001 to October 2003in psychiatric outpatient clinic at the Institute of HumanBehaviour & Allied Sciences, Delhi (India). A large majority ofthe patients attending the service suffer from psychotic disordersincluding schizophrenia, BAD and others, and most of them areaccompanied by their family members, who are also the care-givers.

Patients of schizophrenia and BAD in outpatient care and theircaregivers were screened for the study by the research staff (twopsychologists and a social scientist) under supervision of RKC.Inclusion criteria for the patients included age 15–50 years, diag-nosis of schizophrenia or BAD on International Classification ofDiseases, Diagnostic Criteria of Research (ICD DCR) [35], andavailability of family members or caregivers for assessment. The

patients should have been ill for a minimum period of one year, andclinically stable for a minimum period of 3 months before the study.Clinical stability was defined as no major changes in medication andno hospitalization in the 3 months preceding the intake. Criteria ofclinical stability was included to control for the effects of floridillness on burden, since the florid symptoms are likely to imposehigher burden, which would come down as the symptoms getcontrolled with treatment. Patients with any associated chronicphysical illness, co morbid substance use disorder and having anyliving family member suffering from psychiatric illness staying inthe same household were excluded. To be included in the study, thecaregivers needed to be consenting adults with no history of mentalillness, and should have been caring for the patient for at least oneyear. Written informed consent was taken from the caregivers and/or the patients, as appropriate. The study was approved by theInstitute’s ethics committee.

About 1,000 patients were screened over a period of one yearfor the study, out of whom, 305 (150 of schizophrenia and 155 ofBAD) met the study criteria. All the patients and caregivers con-sented for the study. The patients continued to attend the regularoutpatient services during the period of study. Some of them, whomissed their follow up, were reminded by letters or telephonicallyby the research team to come for assessment. In a few cases, theresearch team also made home visits to carry out the assessment.Since it had been planned to have 200 completed cases, the followup assessments were stopped, once the target was achieved. How-ever, the patients continued to receive the usual outpatient care onfurther follow up in the service.

j Measures

Burden in the caregivers was assessed by Burden AssessmentSchedule (BAS) [32]. BAS is a 40 item structured instrument inEnglish, which assesses both objective as well as subjectiveburden experienced by the caregivers of chronic mentally illpatients. The items are rated on a 3 point scale, marked 1–3 withthe responses being not at all, to some extent, and very much.The instrument has been developed and standardized on Indianpopulation. It is administered by the researcher. BAS has beenreported to have a good inter rater reliability (j 0.80) and sat-isfactory face validity in terms of the relevance of the items inmeasuring caregiver burden [32]. The 40 items have beengrouped into 9 factors: spouse related, physical and mentalhealth, external support, caregiver’s routine, support of patient,taking responsibility, other relations, patient’s behaviour andcaregiver’s strategy. Factors of spouse related burden, physicaland mental health, and other relations refer to the effects ofcaregiving on the sexual and marital relationship, physical andmental health of the caregiver, and relationship with other familymembers and friends respectively. Items in the factor ofcaregiver’s routine refer to the effect of caregiving role on thecaregivers’ day to day activities. Appreciation and support, whichthe caregiver gets from other family members or friends onaccount of caregiving role, form the external support factor.Effect of the patient’s problematic behaviour on family func-tioning is included in the patient’s behaviour factor. The burdenfactors of taking responsibility, support of patient, and caregiverstrategies relate to meeting various needs of the patients, gen-erating finances, planning for future requirements, seeking sup-port from friends and increased work load. There is someoverlap between various factors, burden being a complex con-struct.

Coping strategies used by the caregivers were assessed byWays of Coping Checklist-Hindi Adaptation (WCC-HA), aninstrument adapted from the Ways of Coping Checklist ofFolkman and Lazarus [5]. The original instrument has 28 items,each item rated on a five point likert scale from ‘never’ to ‘allthe time’. Caregivers are asked how often they have used thelisted strategies in the previous 3 months to deal with theproblems while being in contact with their patient. Scazufca andKuipers [30] have used a modified 13 item version of thechecklist in relatives of people with schizophrenia. The modified

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version was translated to Hindi and tested in 30 caregivers forits suitability in the local population. This required some minormodifications. The modified version (WCC-HA) was adminis-tered by the researchers to the caregivers to assess their copingstrategies. The items in the checklist refer to three categories ofcoping strategies; ‘problem focused’, ‘seek social support’, and‘avoidance’. Coping strategies in the problem solving group in-clude assessing the problem, deliberating on various actionswhich could be taken to reduce it, choosing the activities after acareful thought which would be helpful, devising an action planand working out the solution. Seek social support methods referto taking advice and support from specialists, friends or rela-tions; sharing one’s feelings with others, and meeting otherpeople with similar problems. Avoidance strategies in the listinclude resorting to smoking, acting out, wishing a miracle couldhappen and solve the problem, and avoiding meeting others.

Psychopathology in the patients was assessed by the 18 itemversion of Brief Psychiatric Rating Scale (BPRS) [7, 21].

j Assessments

In the first step the research staff was familiarized with the assessmentinstruments. Thirty patients and their caregivers (12 of schizophre-nia and 18 of BPAD) were included in the pilot phase. No majorproblem was faced in administration of questionnaires except in caseof WCC–HA, which needed some minor modifications.

Patients and caregivers fulfilling the inclusion and exclusioncriteria were assessed by the research staff under supervision ofRKC and TBS. Intake started in January 2002 and the follow upassessments finished in July 2003.

Burden and coping strategies of the caregivers, and psychopa-thology in the patients were assessed at intake, and at 3 and 6months follow up on various measures as described earlier.

j Interventions

The patients continued to get the routine outpatient care in thehospital. The patients and caregivers were also offered psychoedu-cation sessions to improve the coping skills in the caregivers andtreatment adherence in the patients. The sessions were conducted bythe research staff with inputs from authors. In the sessions, theparticipants attended a brief presentation about prevalence, clinicalpresentation, common misconceptions and available treatments ofsevere psychiatric illnesses including schizophrenia and BAD usingdisplay materials. The patients and caregivers were also given copiesof some educational material on schizophrenia and BAD in Hindi. Atotal of 22 sessions were organized at a frequency of twice a month.Each session was attended by 4–5 patients and 6–8 caregivers. It wasaimed to cover all the patients and caregivers for educational ses-sions, but only 80 patients and 120 caregivers could attend the ses-sions.

j Analysis

The data was tabulated as per frequency distribution across differentsociodemographic groups. ANOVA and ‘t test’ statistics were used toassess the significance of differences in scores on BAS, WCC-HA andBPRS between the two case groups and at different assessments.Correlation between various burden factors and coping strategieswas studied using Pearson’s product moment correlation.

Results

j Sample characteristics

The initial intake consisted of 305 patients and theircaregivers (150 of schizophrenia and 155 of BAD), out

of which 100 patients and 100 caregivers each ofschizophrenia and BAD completed the 6 months fol-low up. There were no significant differences betweenthe cases and drop outs on various sociodemographicand clinical characteristics.

Thirty six percent of patients with schizophreniawere in the age group 15–30, compared to 44% of theBAD group. About 20% of patients in both groupswere above 40. Seventy five percent of schizophreniapatients and 65% of those of BAD were males. Sixtyfive percent of the patients in both groups weremarried. Nearly one third of the patients had receivedup to 5 years of formal education, about half hadcompleted schooling, and 16% had completed grad-uation. More than half of the patients lived in jointfamilies. More than 80 percent of the patients wereworking. Nineteen percent of schizophrenia patientsand 26% of those of BAD group were housewives.Agriculture, clerical jobs and small scale businesswere the other common professions of the patients.More than 85% patients belonged to low socioeco-nomic group with a monthly income of less than 2,000Indian rupees. The two groups were comparable onmost of the variables, except that 40% of the BADsubjects came from rural background, compared tojust 13% of the schizophrenia group (P < 0.001).

The two caregiver groups were comparable acrossvarious sociodemographic variables. About one fourthof the caregivers each in both the case groups were inthe age groups below 25 and above 50. Fifty eight per-cent of the BAD caregivers and 49% of those from theschizophrenia group were males. About half of themhad received only up to 5 years of formal education.Parents and spouses formed three-fourth of the care-givers. More than 90% of the caregivers were living inthe same household as their patients and were having adaily contact with the patients. Most of the caregiverswere living with their patients for more than 10 years.

Patients belonging to the schizophrenia and BADgroups had similar levels of severity of psychopa-thology as measured on BPRS. Over the 6 monthsfollow up, there was a significant reduction in meanBPRS scores from 32.88 to 28.26 in schizophreniagroup (P = 0.006), and from 31.05 to 27.03 in BADgroup (P = 0.013).

j Burden characteristics

Caregivers from the both the groups had similarpattern of burden as revealed in scores on variousfactors of BAS. The caregivers scored high specificallyon two of the burden factors: taking responsibility,and physical and mental health.

Total score on BAS was compared across differentsociodemographic groups. No significant differencesemerged in total burden scores across various soci-odemographic variables including age, sex, education,family type, income, occupation and residence,though on a few variables, significant differences were

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seen at one of the three assessments. In the BADgroup, caregivers of the married patients perceivedhigher burden than those of the unmarried patients atall the three assessments. In the schizophrenia groupsthis difference was significant at the baseline assess-ment, but not after 3 and 6 months.

Total burden scores as well as scores on variousburden factors did not show any significant differ-ences between the two caregiver groups both atbaseline as well as on follow up (Table 1). No signif-icant change in burden scores was observed on followup, except in the burden factor of taking responsi-bility, where the score declined significantly in care-givers of both the groups over the 6 months follow up(P 0.004 in schizophrenia and 0.002 in BAD).

j Coping strategies

Caregivers from the two groups had comparablescores on the WCC-HA on various coping strategiesboth at the baseline as well as on follow up (Table 2).On the subscale of ‘problem focused strategies’, thecaregivers achieved about two-third of the maximumpossible score (subjects scoring 3 or 4 on most of theitems), whereas the mean score on the ‘seek socialsupport strategies’ was about 40% of the maximumscore (subjects scoring 1–3 on various items), and wasfurther less at just one third (subjects scoring 1–2 onmost of the items) in the ‘avoidance strategies’ sub-group. Thus, the caregivers were using the problemfocused and seek social support types of copingstrategies more often than the avoidance strategies.No significant differences were observed in the use ofdifferent coping strategies across various sociode-mographic groups. Scores on various coping strate-gies did not show any significant change on follow upassessments in both the groups.

j Relationship between burden and coping

Table 3 shows the correlational statistics of the rela-tionship between various burden factors and thecoping strategies. Use of avoidance coping strategiesshowed a positive correlation with many of the bur-den factors like physical and mental health, caregiv-er’s routine, taking responsibility, other relations,patient’s behaviour, and caregiver’s strategy, and alsowith the total burden score in both schizophrenia aswell as the BAD case groups. No consistent correla-tions were observed between burden and the problemfocused strategies in both the case groups. Seek socialsupport coping strategies showed a positive correla-tion with the burden factors of physical and mentalhealth in both the case groups and with the burdenfactors of caregiver’s routine and the patient’sbehaviour in only the BAD group. There were alsosome other significant correlations between some ofthe burden factors and the coping strategies at one of

Table 1 Scores on various burden factors in caregivers of BPAD and schizo-phrenia patients at baseline and follow up (N = 200)

Sub items of BAS BPAD(N = 100)Mean ± SD

Schizophrenia(N = 100)Mean ± SD

Spouse relatedBaseline 3.68 ± 3.23 4.11 ± 3.473 months 3.91 ± 3.48 3.94 ± 3.326 months 3.93 ± 3.48 4.14 ± 3.56Physical and mental healthBaseline 10.73 ± 3.35 10.48 ± 3.293 months 10.90 ± 3.57 10.66 ± 3.526 months 10.50 ± 3.48 10.30 ± 3.53External supportBaseline 7.66 ± 2.68 7.41 ± 2.803 months 7.45 ± 2.74 7.42 ± 2.926 months 7.20 ± 2.70 7.44 ± 2.81Caregiver’s routineBaseline 5.72 ± 1.71 5.60 ± 1.653 months 5.71 ± 1.82 5.24 ± 1.666 months 5.38 ± 1.80 5.40 ± 1.57Support of patientBaseline 4.42 ± 1.29 4.11 ± 1.143 months 4.19 ± 1.36 4.26 ± 1.406 months 4.20 ± 1.16 4.50 ± 1.12Taking responsibilityBaseline 10.04 ± 2.65 10.20 ± 2.333 months 9.47 ± 2.87 9.53 ± 2.826 months 8.66 ± 2.86* 8.90 ± 3.02**

Other relationsBaseline 4.10 ± 1.34 3.93 ± 1.353 months 4.11 ± 1.45 3.88 ± 1.136 months 3.86 ± 1.17 4.02 ± 1.42Patient’s behaviourBaseline 5.91 ± 2.00 5.66 ± 1.973 months 5.98 ± 2.32 5.45 ± 1.716 months 5.67 ± 2.22 5.70 ± 2.09Caregivers’ strategyBaseline 6.73 ± 2.07 6.80 ± 1.833 months 6.49 ± 2.37 6.48 ± 2.246 months 5.96 ± 2.11 6.27 ± 2.33OthersBaseline 3.86 ± 1.35 3.12 ± 1.223 months 3.69 ± 1.44 3.35 ± 1.366 months 3.53 ± 1.37 3.52 ± 1.55BAS—TotalBaseline 62.85 ± 13.49 61.41 ± 12.683 months 61.90 ± 15.75 60.21 ± 13.636 months 58.89 ± 15.58 60.19 ± 14.51

* F value 5.58, P = 0.004, ** F value 6.13, P = 0.002

Table 2 Scores on WCC-HA in caregivers of BAD and schizophrenia patients

Scores on WCC-HA BAD(N = 100)Mean ± SD

Schizophrenia(N = 100)Mean ± SD

Problem focused (max. score 15)Baseline 9.89 ± 2.55 9.62 ± 2.663 months 10.39 ± 2.67 10.32 ± 2.746 months 10.10 ± 2.73 10.54 ± 3.14Seek social support (max. score 20)Baseline 8.29 ± 2.75 8.06 ± 2.553 months 8.29 ± 2.40 7.80 ± 2.446 months 8.01 ± 2.51 7.99 ± 2.08Avoidance baseline (max. score 30)Baseline 10.65 ± 2.52 10.39 ± 2.253 months 10.88 ± 2.53 10.17 ± 2.226 months 10.54 ± 2.40 10.58 ± 2.20

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the assessments (e.g. a negative correlation betweenthe burden factor of spouse related and the problemfocused coping at 6 months assessment in theschizophrenia group), but these were not consistentacross all the assessments.

Discussion

In the present study, patients with schizophrenia andBAD were found to impose similar levels of burden ontheir caregivers. Both the caregiver groups adoptedproblem solving and seek social support type ofcoping strategies more often than the avoidancestrategies. A positive correlation was, however, ob-served between various burden factors and the use ofavoidance strategies in both the caregiver groups.

Patients and caregivers in the two illness groupswere similar in most of the sociodemographic char-acteristics, except for an over representation fromrural area in the BAD group, a chance finding.Majority of the patients were males, a usual pattern in

the Indian health settings. Most of our patients weregainfully employed, having recovered from the acuteillness and being clinically stable. However, we don’thave any information on their level of functioning injob. Caregivers of married patients with BAD expe-rienced higher burden than those of the unmarried atall the three assessments and those of schizophreniaonly at the baseline. This could be because the mar-ried patients with the additional responsibility of theirspouse and children are likely to impose more burdenon their caregivers. No other differences in burdenand coping were observed across various sociode-mographic variables in both the caregiver groups.

Schizophrenia has been identified as contributingto caregiver burden for a long time [1, 4, 6, 31].Affective disorders due to their episodic nature wouldbe expected to cause lesser burden than schizophre-nia, which is mostly identified with a chronic course.Some earlier studies had also shown such results [3,29], refuted by the later studies, which reported sub-stantial burden in caregivers of patients with BAD,comparable to that seen in schizophrenia [2, 20, 24].

Table 3 Correlation between scoreson burden factors and copingstrategies in schizophrenia and BADpatients

Burden factors Months Coping factors

Problemfocused

Seeking socialsupport

Avoidance

Schiz BAD Schiz BAD Schiz BAD

Spouse related 0 )0.02 )0.19 )0.05 0.02 0.15 0.24*3 )0.17 )0.17 )0.12 )0.07 0.02 0.186 )0.29** )0.06 )0.01 0.11 )0.01 0.16

Physical and mental health 0 )0.02 )0.04 0.28** 0.38** 0.46** 0.41**3 )0.21* 0.07 0.21* 0.30** 0.51** 0.28**6 )0.12 0.17 0.20* 0.32** 0.50** 0.45**

External support 0 )0.32** )0.29** )0.06 )0.16 0.06 0.153 )0.16 )0.1 )0.06 )0.25* 0.13 0.026 )0.02 )0.16 )0.04 )0.11 0.12 0.17

Caregiver’s routine 0 )0.10 )0.02 0.03 0.26** 0.37** 0.35**3 )0.25* )0.08 0.14 0.21* 0.32** 0.25*6 )0.12 0.12 0.08 0.22* 0.37** 0.43**

Support of patient 0 )0.18 )0.07 )0.05 )0.15 0.07 0.063 )0.15 )0.13 )0.04 )0.19 0.20* 0.24*6 )0.00 0.05 )0.14 0.18 0.16 0.19

Taking responsi-blity 0 )0.19 0.06 0.02 0.07 0.25* 0.30**3 )0.11 )0.1 0 0.03 0.28** 0.30**6 0.17 0.09 0.04 0.02 0.37** 0.40**

Other relations 0 0.04 )0.08 0.27** 0.17 0.22* 0.35**3 )0.09 )0.08 0.16 0.05 0.42** 0.27**6 0.13 0.16 0.01 0.13 0.36** 0.33**

Patient’s behaviour 0 0.05 0.07 0.2 0.38** 0.46** 0.37**3 )0.12 0.05 0.18 0.37** 0.53** 0.31**6 )0.01 0.20* 0.19 0.28** 0.48** 0.39**

Caregiver’s strategy 0 )0.16 )0.1 )0.05 )0.05 0.25* 0.143 )0.18 )0.21* 0.06 0.01 0.46** 0.33**6 0.07 )0.05 0.03 0.03 0.42** 0.34**

Others 0 0.05 0.03 0.22* 0.18 0.31** 0.37**3 )0.09 )0.01 0.14 0.09 0.36** 0.29**6 0.12 0.15 0.07 0.23* 0.27** 0.33**

BAS-T (Total score) 0 )0.15 )0.12 0.12 0.19 0.44** 0.45**3 )0.29** )0.14 0.1 0.1 0.52** 0.40**6 )0.09 0.07 0.27** 0.17 0.48** 0.46**

Values given are of Pearson Correlation* Correlation is significant at the 0.01 level (2-tailed)** Correlation is significant at the 0.05 level (2-tailed)

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This finding is further confirmed by the present study,which had also the advantage of being longitudinal innature. The finding of comparable levels of caregiverburden in BAD, as in schizophrenia, emphasizes theneed to devote equivalent levels of resources towardsBAD, which has sometimes not been given as muchimportance [17].

We did not find a significant change in burdenover the 6 months follow up, though there was somereduction in the severity of illness. However, therewas a fall in scores on the burden factor of takingresponsibility. Earlier workers have reported con-flicting findings on the subject. For example, Magli-ano et al. [13] did not find any major changes inburden over a year in their longitudinal study oncaregivers of patients with schizophrenia, though areduction in family burden was observed among rel-atives who adopted less emotion focused copingstrategies and received more practical support fromtheir social network. Improvement of patient’s socialfunctioning was associated with reduction in theburden. However, some other studies have reportedreduction in burden in caregivers of schizophreniapatients following treatment and psychoeducationalinterventions in periods varying from 3 to 30 months[15, 16, 18, 28]. Somewhat similar findings have beenreported in bipolar disorders [8, 26], though there arenot many longitudinal studies. Heru and Ryan [8] inone year follow up of the caregivers of the mooddisorders patients who were discharged from thehospital, found significant reduction in burden inbipolar group, but no change in the caregivers ofpatients with depression. In another study on bipolardisorders, psychoeducational interventions werefound to reduce the subjective burden, but did nothave any effect on the objective burden [26].

Maladaptive ways of functioning in the family andthe expressed emotions are associated with increasein the perceived burden and affect caregiving. Familyinterventions and pychoeducational approaches couldbe helpful here. In fact, psychoeducational ap-proaches have specifically been reported to reduce theseverity of illness along with associated disability andburden, and also improve communication in thefamily [15, 18]. We had also used psychoeducationalinterventions in our study, but all caregivers couldnot be covered. More so, the interventions were not asintensive and as structured as used in earlier works[15, 26]. The two groups of caregivers who receivedthe psychosocial interventions and who did not re-ceive might have had some differences on follow up,but these were not analyzed. This could be one reasonfor no change in burden seen on follow up, but ap-pears unlikely since the caregivers had received justone or two sessions of the psychoeducational inter-ventions. The reason for no change in caregiverburden over time in our study could also be that ourpatients were clinically stable before being included inthe study.

In this study, caregivers of schizophrenia and BADpatients were found to use similar kind of copingstrategies to deal with their burden. Both the caregivergroups used the problem focused and seek socialsupport coping strategies more often than the avoid-ance strategies. In some of the earlier studies, care-givers of patients with schizophrenia have beenreported to use emotion focused strategies more oftenthan those caring BAD patients [2]. Another com-parative study of burden from the same centre [19]has reported more frequent use of coercive copingand resorting to behaviours like smoking, drinking ortaking pills by caregivers of patients of schizophreniathan those of BAD patients. However, both thesestudies were cross sectional in nature.

Coping styles are affected by caregiver burden anddistress [2]. In our study, though the caregivers weremore often using the healthier coping methods ofproblem solving and seek social support, a positivecorrelation was observed between use of avoidancestrategies and various burden factors. Some of theburden factors like physical and mental health, care-giver’s routine and patient’s behaviour positivelycorrelated with the use of seek social support copingstrategies in the BAD group. A positive correlation ofseek social support strategies was also seen with theburden factor of physical and mental health inschizophrenia group. Scazufca and Kuipers [30] havealso earlier reported a positive correlation betweenburden, and use of avoidance and seek social supporttype of coping strategies in their sample of caregiversof patients with schizophrenia.

There was a dropout of nearly one third of sampleover the 6 months follow up. However, this may nothave affected the results as the patients and caregiverswho dropped out did not differ from the completerson various sociodemographic and clinical character-istics. Dropout could be a due to a number of reasons.Caregivers and the patients may not have felt the needfor follow up because the patients were clinicallystable. Clinical services in India and this part of theworld are often not appointment based and anybodywho registers on a day in a clinical service is seen bythe doctor. Since the service seekers are not in habitof keeping the appointment, this could also be areason for high dropout. In addition, it is possible toget the medications from the private pharmacy shopswithout a fresh prescription (though the local lawdoes not permit it). Thus many times, the patientstake medications directly from the pharmacies, if theyare not able to visit the doctor.

The study had a few limitations. It did not have arandom design and the assessors were not blind to thetwo groups. Adherence to treatment was not assessedformally except for confirming from the patients andcaregivers that the patients were taking their medi-cations. No comparisons were made between patientsand caregivers, who attended the psychoeducationsessions and those who could not attend. There were

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no assessments of the level of patient’s functioning,which is an important variable affecting the caregiverburden.

To conclude, the present study compared pro-spectively caregivers of clinically stable patients oftwo severe mental disorders (schizophrenia and BAD)on their perception of burden and coping. Both thegroups of caregivers suffered nearly similar level ofburden and used similar pattern of coping strategies.Further longitudinal studies are required on burdenand coping in caregivers of patients with severemental disorders to understand their complex rela-tionship. The study also emphasizes the need of pol-icy planners to devote more resources towards theBAD, which imposes about the similar levels of bur-den as schizophrenia, and has been ignored some-times.

j Acknowledgements The authors are grateful to the IndianCouncil of Medical Research for financially supporting the study;Professor N.G. Desai and Dr. D.K. Gupta, Department of Psychiatryand Professor J.S. Bapna former Director, Institute of HumanBehaviour and Allied Sciences, Dilshad Garden, Delhi 110095, Indiafor their help and contributions to the work at different stages; andDr. H.C. Joshi, Ms Ashima Srivastava and Ms Himali Bangia, theresearch staff of the study. The authors would also like to expresstheir thanks to Dr. S.K. Khandelwal, Professor of Psychiatry, AllIndia Institute of Medical Sciences, New Delhi, India for his valu-able comments on the manuscript.

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