Towards a better understanding of caregiver distress in early psychosis: a systematic review of the psychological factors involved

Important first encounter: Service user experience of pathways to care and early detection in first-episode psychosis

BACKGROUND

Long duration of untreated psychosis is associated with poor clinical and functional outcomes. However, few systematic attempts have been made to reduce this delay and little is known of service users' experience of early detection efforts.

AIM

We explored service users' experience of an early detection service and transition to specialized treatment service, including pathway to care, understanding of illness and barriers to adequate assessment and treatment.

METHODS

In-depth interviews were conducted with 10 service users (median age 21, range 18-27, five males and five females) who were diagnosed with a first-episode non-affective psychosis and who were seen by an early detection team (TOP) and currently enrolled in a specialized early intervention service for this disorder (OPUS).

RESULTS

Stigma and fear of the 'psychiatric system' were reported as significant barriers to help seeking, while family members were seen as a crucial support. Moreover, the impact of traumatic events on the experience and development of psychosis was highlighted. Finally, participants were relieved by the prospect of receiving help and the early detection team seemed to create a trusting relationship by offering a friendly, 'anti-stigmatized' space, where long-term symptomatology could be disclosed through accurate and validating questioning.

CONCLUSIONS

Early detection services have two important functions. One is to make accurate assessments and referrals. The other is to instil hope and trust, and to facilitate further treatment by forming an early therapeutic alliance. The findings in this study provide important insights into the way in which early detection efforts and pathways to care are experienced by service users, with direct implications for improving psychiatric services.

Quality of life in caregivers with and without chronic disease: Welsh Health Survey, 2013

Background

The aim of the present study was to investigate and compare quality of life after regular care provision in people with and without currently treated chronic disease in a country-wide and population-based setting.

Methods

Data were retrieved from Welsh Health Survey, 2013. Information on demographics, lifestyle factors, health conditions, regular care provision and quality of life was obtained by household interview. Chi-square test, t-test and survey-weighted multi-nominal regression modelling were performed.

Results

Of 15 007 Welsh adults aged 16 and above, 2751 (19.1%) people reported that they have been giving care for any sick, disabled or frail person. They tended to be aged 40-74, being female, education <degree, body mass index >25, physically active, current smokers and living in second-hand smoking households. In caregivers with current chronic disease (n = 1562), they have experienced physical health limits, bodily pains, emotional problems, less calm and less cheerful. In caregivers without current chronic diseases (n = 1151), they have experienced physical health limits, bodily pains, less cheerful, downhearted and unhappiness.

Conclusions

This is the first study to examine quality of life in caregivers both with and without currently treated chronic disease. Longitudinal monitoring and increasing education, training and support to lessen caregiving burden would be suggested.

Social functioning in individuals with first episode psychosis: One-year follow-up study

BACKGROUND

Improvement in social functioning is important for recovery in first episode psychosis (FEP).

METHODOLOGY

51 individuals diagnosed with first episode psychosis were assessed for social functioning at baseline and one year follow-up.

RESULTS

Significant improvement was seen in certain domains of social functioning measured by LSP scale such as communication and non-turbulence while no significant changes were observed in self-care and social contact.

CONCLUSION

At one year follow-up, partial improvement in social functioning is observed in individuals with first episode psychosis. This warrants inclusion of specific interventions to improve social functioning in the management plan of individuals with FEP.

Acceptance and perceived usefulness of robots to assist with activities of daily living and healthcare tasks

As the number of older adults living with chronic conditions continues to rise, they will require assistance with activities of daily living (ADL) and healthcare tasks to continue living independently in their homes. One proposed solution to assist with the care needs of an aging population and a shrinking healthcare workforce is robotic technology. Using a cross-sectional survey design, we purposively sampled adults (≥18 years old) to assess generational acceptance and perceived usefulness of robots to assist with ADLs, healthcare tasks, and evaluate acceptance of robotic healthcare assistance across different settings. A total of 499 adults (age range [years] 18-98, Mean = 38.7, SD = 22.7) responded to the survey. Significant differences were found among young, middle-aged, and older adults on perceived usefulness of robots for cleaning, escorting them around town, acting as companionship, delivering meals, assessing sadness and calling for help, providing medical advice, taking vital sign assessments, and assisting with personal care (p < 0.05). The majority of younger adults reported that they would like a robot to provide healthcare assistance in the hospital, compared to middle-aged and older adults (p < 0.001). Results of this study can guide the design of robots to assist adults of all ages with useful tasks.

Psychological Flexibility as a Buffer against Caregiver Distress in Families with Psychosis

Background: Research has shown that caregivers of persons with psychosis play an invaluable role in recovery, but unfortunately, often report high levels of distress. While cognitive models of caregiver distress have been well-supported, there is still limited knowledge of the psychological factors involved. Recent advances in cognitive behavioral therapy seem to converge on the importance of acceptance- and mindfulness based processes.

Aim: To examine the impact of psychological flexibility on caregiver distress in the early phases of psychosis, while controlling for known predictors of caregiver distress.

Method: Within a cross-sectional design, 101 caregivers of 38 persons with first-episode psychosis in a clinical epidemiological sample completed a series of self-report measures.

Results: A linear mixed model analysis found that, after controlling for caregiver socio-demographic factors, service user symptoms, drug use and global functioning, psychological flexibility was a significant predictor of caregiver distress.

Conclusion: Greater level of psychological flexibility in caregivers, seems to be related to lower levels of caregiver distress. This finding corresponds to studies within a broad range of emotional disorders. There may be important clinical implications in terms of facilitating the process of acceptance through interventions from the ‘third-wave’ or contextual cognitive behavioral therapies.

A longitudinal population-based study of carers of people with psychosis

AIMS

Few studies have examined the experiences of carers of people with psychosis using a representative sample. Aiming to obtain generalisable results concerning carers in the context of increased emphasis on involving carers in Australian mental health service delivery and policy frameworks, this study recruited carers within the second Australian national survey of psychotic disorders (Survey of High Impact Psychosis, SHIP). Given that most SHIP participants had long-term illness and extended relationships with carers, the health and wellbeing of carers as a group were expected to be relatively stable. However, since it is unknown whether carers' health and wellbeing would change, our main aim was to explore change and stability in carers' health and wellbeing and the relationship between any changes experienced by individual carers and corresponding SHIP participants' functioning over time.

METHODS

Ninety-eight caregivers of SHIP participants were recruited at baseline and completed validated instruments assessing their health and wellbeing. Seventy-eight carers were re-interviewed at 1-year follow-up. Clinical factors were extracted from the SHIP database. Wilcoxon matched-pairs signed-rank test and t-test were used to analyse changes in variables over time. Cross-lagged analyses were conducted to identify possible causative relationships in changes in SHIP participant and carer variables.

RESULTS

A substantial percentage of carers experienced social isolation (28.6%), psychological distress (37.7%) and poorer quality of life than population norms. There were no statistically significant changes between baseline and follow-up scores for almost all carers' health and wellbeing variables, other than a poorer perception of their quality of life in relation to their physical health after 1 year. Cross-lagged analyses suggested that poorer functioning of people with psychosis influenced carers' social isolation, grief and psychological distress.

CONCLUSIONS

Findings show that carers' perception of their health and wellbeing did not improve within current mental health service delivery frameworks over time. Carer's persistently poor health and wellbeing suggests a pressing need to enhance services that improve carers' health and wellbeing especially their physical health and the functioning of people with psychosis whom they support.

Metacognitive mastery in persons with first-episode psychosis and their caregivers: Implications for timely help-seeking and caregiver experiences. Brief report

While metacognitive mastery seems to be closely linked to general functioning in persons with psychosis, little is known of metacognitive capacity of family members, who often play an important role in recovery and often report high levels of distress. We gathered assessments of metacognitive mastery from persons with first-episode psychosis and their mothers. We found that relatively higher overall mean mastery levels among the dyads, was related to less negative caregiver experiences, and less caregiver criticism. Greater levels of mastery were related to decreased duration of untreated psychosis. Clinical implications in terms of family intervention programmes repertoire are discussed.

Caring for an intimate stranger: parenting a child with psychosis

WHAT IS KNOWN ON THE SUBJECT

The care of an adult son or daughter with psychosis is filled with overwhelming demands caused by the symptomatology and illness exacerbations. Parents display disenfranchised grief over multiple losses and report increased levels of emotional burden. Most studies use quantitative methods and rely on pre-existing theoretical frameworks to investigate, through psychometric measures, the effects of being a carer. Meaning attributions to the disorder, and changes in parent-child relations over time, are poorly understood.

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE

This hermeneutic phenomenological study illuminates the subjective experience of parenting a son or daughter with psychosis, as it is lived and described by parents of young adults with psychosis. Findings suggest that the parents' perceptions of their child changes over the course of the disorder, leading to a redefinition of the parent-child relationship, causing alternations in attachment. Findings illuminate the parents' profound guilt over having contributed or not prevented the disorder, over not being 'good' parents and feeling ambivalent towards an 'intimate stranger.' Guilt is compensated by absolute dedication to the son or daughter's care, at the expense of their own well-being.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Interventions for parents must be available as soon as possible, both during hospitalization and after discharge. Professionals should provide a therapeutic space, where parents could express intimate thoughts and feelings, address guilt, fear and resentment issues, be assisted in their parenting role as well as in the reconstruction of a sense of self and self-esteem. Professionals are invited to facilitate illness acceptance, provide accurate information, assist parents to redefine their relationship to the child and facilitate the integration of the traumatic experience into their personal and family narrative. Professionals must develop in depth awareness of their biases and attitudes, have an ongoing training on how to respond to the parents' needs, facilitate therapeutic change and accompany families through the course of their adult child's illness trajectory.

ABSTRACT

Introduction Children who are diagnosed with psychosis often rely on their parents for prolonged care. The impact of such care is partially understood as most studies use quantitative methods and pre-existing theoretical frameworks that limit their investigation to emotional burden, and emotional responses. Aim Explore the parents' lived experience of caring for a child with psychosis. Method A hermeneutic phenomenological design was used with a sample of 16 parents of children with psychotic disorders who were hospitalized or attended the outpatient clinic of a large psychiatric Greek hospital. Results Identified themes were as follows: (i) the psychosis experience, (ii) redefinition of the parent-child relationship over the course of the disorder and (iii) challenges of parenting a child with psychosis. Discussion 'Caring for an intimate stranger' reflects the parents' overall experience, involving changes in the parent-child relationship, ambivalence towards caretaking and profound guilt, compensated by self-sacrifice parenting practices.

IMPLICATIONS FOR PRACTICE

Findings highlight the necessity to train mental health professionals to provide individualized information; facilitate family communication; address the parents' guilt, ambivalence, meaning attributions that compromise adjustment; and support them through the challenges of parenting a son or daughter with psychosis.

The emotional health and well-being of Canadians who care for persons with mental health or addictions problems

The purpose of this project was to examine the emotional health and well-being of Canadian caregivers of persons with significant mental health or addictions problems. We assessed the emotional health of caregivers by care-receiver condition type (i.e. mental health or addictions vs. physical or other health problems), levels of caregiver stress and methods particularly for reducing stress among caregivers of persons with mental health or addictions disorders. Weighted cross-sectional data from the 2012 General Social Survey (Caregiving and Care Receiving) were modelled using weighted descriptive and logistic regression analyses to examine levels of stress and the emotional health and well-being of caregivers by care-receiver condition type. Caregivers of persons with mental health or addictions problems were more likely to report that caregiving was very stressful and that they felt depressed, tired, worried or anxious, overwhelmed; lonely or isolated; short-tempered or irritable; and resentful because of their caregiving responsibilities. The results of this study suggest that mental health and addictions caregivers may experience disparate stressors and require varying services and supports relative to caregivers of persons with physical or other health conditions.

Moderated Online Social Therapy: A Model for Reducing Stress in Carers of Young People Diagnosed with Mental Health Disorders

Family members caring for a young person diagnosed with the onset of mental health problems face heightened stress, depression, and social isolation. Despite evidence for the effectiveness of family based interventions, sustaining access to specialist family interventions is a major challenge. The availability of the Internet provides possibilities to expand and sustain access to evidence-based psychoeducation and personal support for family members. In this paper we describe the therapeutic model and the components of our purpose-built moderated online social therapy (MOST) program for families. We outline the background to its development, beginning with our face-to-face EPISODE II family intervention, which informed our selection of therapeutic content, and the integration of recent developments in positive psychology. Our online interventions for carers integrate online therapy, online social networking, peer and expert support, and online social problem solving which has been designed to reduce stress in carers. The initial version of our application entitled Meridian was shown to be safe, acceptable, and feasible in a feasibility study of carers of youth diagnosed with depression and anxiety. There was a significant reduction in self-reported levels of stress in caregivers and change in stress was significantly correlated with use of the system. We have subsequently launched a cluster RCT for caregivers with a relative diagnosed with first-episode psychosis. Our intervention has the potential to improve access to effective specialist support for families facing the onset of serious mental health problems in their young relative.

Expressed Emotion and Attributions in Relatives of Patients With Obsessive-Compulsive Disorder and Panic Disorder

Relatives' criticism of, hostility toward, and emotional overinvolvement (EOI) with patients are predictive of treatment response and relapse. Although these constructs have been linked to relatives' attributions for patient problems, little research has yet evaluated attributions for specific types of problems. This study examined event-specific attributions (i.e., attributions specifically for either disorder-related [DR] or non-DR problems) in relatives of patients with anxiety disorders. Relatives made more illness attributions (attributing problems to a patient's disorder) than controllable attributions (attributing problems to factors controllable by patients) for DR events, with the reverse pattern for non-DR events. Criticism and hostility were associated primarily with controllability attributions for non-DR events. In contrast, the presence of EOI was associated with illness attributions for non-DR events. Family-based interventions for anxiety disorders might need to focus on relatives' controllability attributions for a broad range of patient behaviors and on reducing tendencies to attribute non-DR problems to patients' disorders.

Do Family Interventions Improve Outcomes in Early Psychosis? A Systematic Review and Meta-Analysis

Family interventions for psychosis (FIp) are effective in reducing service user relapse and carer distress in people with schizophrenia-spectrum conditions. Several treatment and best practice guidelines recommend FIp for all people with schizophrenia. However, outcome findings in relation to early psychosis groups have been inconsistent. The current paper reports a systematic review and meta-analyses of articles that evaluated FIp in early psychosis with a clearly defined comparison group. A combination of electronic database searches (using PsychINFO, Medline, and CENTRAL), citation searches and hand searches of key journals and reviews was conducted. Peer-reviewed articles published in English from database inception to June 2016 were included. Methodological quality was assessed using the Effective Public Health Practice Project Quality Assessment Tool (EPHPP). Seventeen papers from 14 studies met inclusion criteria for review, the overall quality of which was moderate. Meta-analytic synthesis showed that FIp improved service user functioning and reduced the likelihood of relapse by the end of treatment. Psychotic symptoms were significantly reduced in the FIp group at follow up, but this was not evident at end of treatment. In terms of FIp target mechanisms, carers receiving FIp were more likely to shift from high to low expressed emotion and less likely to report patient focused criticism or engage in conflict communication than carers randomized to standard care. Carer burden and well-being were improved by the end of treatment but gains were not sustained at follow up. FIp had no impact on carer emotional over-involvement. The findings indicate that FIp is an effective intervention for early psychosis service users and their relatives. However, further research is required to establish which key therapeutic components of FIp are most effective for whom, in addition to understanding the mechanisms by which FIp might affect positive change.

Guilt, shame and expressed emotion in carers of people with long-term mental health difficulties: A systematic review

Expressed emotion (EE) is a global index of familial emotional climate, whose primary components are emotional over-involvement (EOI) and critical comments (CC)/hostility. There is a strong theoretical rationale for hypothesising that carers' guilt and shame may be differentially associated with their EOI and CC/hostility respectively. This systematic review investigates the magnitude of these theorised associations in carers of people with long-term mental health difficulties. Electronic searches (conducted in May 2016 across Medline, CINAHL, Embase, PsycINFO and ProQuest) were supplemented with iterative hand searches. Ten papers, reporting data from eight studies, were included. Risk of bias was assessed using a standardised checklist. Relevant data were extracted and synthesised narratively. EOI was positively associated with both guilt and shame, whereas CC/hostility was positively associated with shame. The strength of associations varied depending on whether or not guilt and shame were assessed within the context of the caring relationship. Based on these data, an argument can be made for the refinement, development and evaluation of systemic and individual interventions designed to target carers' guilt and shame. However, more research is needed to clarify the strength of these associations and their direction of effect before firm conclusions can be drawn.

Do stress and support matter for caring? The role of perceived stress and social support on expressed emotion of carers of persons with first episode psychosis

BACKGROUND

Caring for a person with first episode psychosis (FEP) is a challenging and distressing task for the carers. The carers' stress in the early stage of psychosis can increase their expressed emotion (EE) while social support is hypothesized to decrease EE. However, the influence of stress and social support on carers' EE is not well understood in FEP.

AIM

To examine how the stress and social support shape expressed emotion in the carers of FEP.

METHODS

Seventy one carers of the patients with non-affective FEP were recruited from the inpatient psychiatry ward of a tertiary mental health care center in South India. The family questionnaire, perceived stress scale and multidimensional scale of perceived social support were used to measure their EE, stress and social support respectively.

RESULTS

Carers experienced high level of perceived stress, EE and poor social support. Perceived stress significantly increased EE (β=0.834; p<0.001) and social support did not significantly influence EE (β=-0.065; p>0.05). Perceived stress predicted 76 percent of the variance on EE (Adjusted R²=0.761).

CONCLUSION

The results emphasize high level of stress and EE in carers of patients with FEP that implies the need for appropriate psychosocial interventions to manage their stress.

Moderated online social therapy for carers of young people recovering from first-episode psychosis: study protocol for a randomised controlled trial

BACKGROUND

First-episode psychosis most often has its onset during late adolescence. In caring for the young person, families endure high levels of stress and depression. Meanwhile, the social networks of families often erode. Our group has previously shown that family cognitive behaviour therapy (CBT) leads to significantly improved perceived stress compared with specialist first-episode treatment as usual; however, there are well-known barriers to the dissemination of effective family interventions. To address this, we have developed a novel online intervention entitled 'Altitudes' that fully integrates purpose-built online social networking, expert and peer moderation, and evidence-based psychoeducation within a single application. The primary aim of this trial is to evaluate the effectiveness of Altitudes in reducing stress in carers over a 6-month period.

METHODS/DESIGN

We describe here a single-blinded cluster randomised controlled trial (cRCT) with permutated blocks. The clusters comprise individual families. The two treatment conditions include Altitudes plus Specialist Treatment as Usual (STAU) and STAU alone. Altitudes involves participation in our novel online programme whereas STAU comprises specialist family work at the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne, Australia. We aim to recruit 160 family members of young, 15-27 year-old, patients registered for treatment for first-episode psychosis (FEP) at EPPIC. The design includes two assessment time points, namely, baseline and 6-month follow-up. The study is due for completion within 2 years including an 18-month recruitment period and a 6-month treatment phase. The primary outcome is carers' perceived stress at 6 months. Secondary outcome measures include a biomarker of stress, depressive symptoms, worry, substance use, loneliness, social support, satisfaction with life, and a range of measures that tap into coping resources. We seek to gain a dynamic picture of carer stress through our Smartphone Ecological Momentary Assessment (SEMA) tool.

DISCUSSION

This is the first randomised controlled trial designed to evaluate an online intervention for carers of young people recovering from FEP. It has the potential to produce evidence in support of a highly novel, accessible, and cost-effective intervention to reduce stress in carers who are providing support to young people at a critical phase in their recovery from psychosis.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry, identifier: ACTRN12616000968471 . Retrospectively registered on 22 July 2016.

Relatives' expressed emotion, distress and attributions in clinical high-risk and recent onset of psychosis

It has been well-demonstrated that Expressed Emotion (EE) in caregivers of schizophrenia patients is related to their illness attributions, but little is known about relatives' cognitive and emotional appraisals at early stages of psychosis. This study examined differences on the relationships of EE with distress and illness attributions in 78 relatives of At-Risk Mental States (ARMS) and First-Episode of Psychosis (FEP) patients, and which of those variables better predicted EE. Criticism and Emotional Over-Involvement (EOI) were associated with distress and with several illness attributions in both groups. Anxiety was more strongly associated with criticism in ARMS than in FEP-relatives, and it was associated with EOI in the ARMS but not in the FEP-group. No differences on the relationships of EE with depression or attributions were found. Furthermore, distress and attributions of blame toward the patients predicted criticism. Attributions of control by the patient and emotional negative representation about the disorder predicted EOI. Findings highlight the need to focus on early family interventions that provide proper information and psychological support in accordance with the illness stage, to help relatives improve their understanding of the disorder, handle difficult thoughts and emotions, reduce negative appraisals, and prevent high-EE over the psychotic process.

Current Data on and Clinical Insights into the Treatment of First Episode Nonaffective Psychosis: A Comprehensive Review

Implementing the most suitable treatment strategies and making appropriate clinical decisions about individuals with a first episode of psychosis (FEP) is a complex and crucial task, with relevant impact in illness outcome. Treatment approaches in the early stages should go beyond choosing the right antipsychotic drug and should also address tractable factors influencing the risk of relapse. Effectiveness and likely metabolic and endocrine disturbances differ among second-generation antipsychotics (SGAs) and should guide the choice of the first-line treatment. Clinicians should be aware of the high risk of cardiovascular morbidity and mortality in schizophrenia patients, and therefore monitoring weight and metabolic changes across time is mandatory. Behavioral and counseling interventions might be partly effective in reducing weight gain and metabolic disturbances. Ziprasidone and aripiprazole have been described to be least commonly associated with weight gain or metabolic changes. In addition, some of the SGAs (risperidone, amisulpride, and paliperidone) have been associated with a significant increase of plasma prolactin levels. Overall, in cases of FEP, there should be a clear recommendation of using lower doses of the antipsychotic medication. If no or minimal clinical improvement is found after 2 weeks of treatment, such patients may benefit from a change or augmentation of treatment. Clinicians should provide accurate information to patients and relatives about the high risk of relapse if antipsychotics are discontinued, even if patients have been symptom free and functionally recovered on antipsychotic treatment for a lengthy period of time.

Linking family cohesion and flexibility with expressed emotion, family burden and psychological distress in caregivers of patients with psychosis: A path analytic model

The present study aimed to evaluate a path analytic model accounting for caregivers' psychological distress that takes into account perceived family cohesion and flexibility, expressed emotion and caregiver's burden associated with the presence of mental illness in the family. 50 first-episode and 50 chronic patients diagnosed with schizophrenia or bipolar disorder (most recent episode manic severe with psychotic features) recruited from the Inpatient Psychiatric Unit of the University Hospital of Heraklion, Crete, Greece, and their family caregivers participated in the study. Family functioning was assessed in terms of cohesion and flexibility (FACES-IV), expressed emotion (FQ), family burden (FBS) and caregivers' psychological distress (GHQ-28). Structural equation modelling was used to evaluate the direct and indirect effects of family dynamics on caregivers' psychological distress. The results showed that neither family cohesion nor family flexibility exerted significant direct effects on caregivers' psychological distress. Instead, the effect of flexibility was mediated by caregivers' criticism and family burden indicating an indirect effect on caregivers' psychological distress. These results apply equally to caregivers of first episode and chronic patients. Family interventions aiming to improve dysfunctional family interactions by promoting awareness of family dynamics could reduce the burden and improve the emotional well-being of family caregivers.

The Experience of Childhood Trauma and Its Influence on the Course of Illness in First-Episode Psychosis: A Qualitative Study

Persons with schizophrenia spectrum disorders often report high levels of childhood trauma, which often exacerbates symptoms and impede the process of recovery. However, little is known about how these traumas are experienced by service users and how they are integrated in their life stories. To examine this, we conducted in-depth interviews with 15 service users with a diagnosis of a first-episode nonaffective psychosis who had reported 1 or more childhood traumas in self-report measures. There was an unexpected discrepancy between the number of traumas reported in self-report measures and in semistructured interviews, and many of the traumas did not seem integrated in their personal narratives. The analyses further revealed that although participants often described complicated and traumatic childhood environments, they still felt supported by their families; they reported a range of ways in which they tried to cope with and gain control of their psychotic disorder, and they described a general optimistic view of the future.

Assessing quality of life in Welsh carers with and without back pain

BACKGROUND

The author aimed to study the prevalence and characteristics of care provision in Welsh adults with and without back pain, as well as their quality of life. The study used a country-wide and population-based setting from an independent dataset.

METHOD

Data were retrieved from and analysed in the Welsh Health Survey 2013. Information on demographics, lifestyle factors, regular care provision, and quality of life was obtained from household interviews. Chi-square tests, t-tests, and survey-weighted multinomial regression modelling were performed.

RESULTS

Of 15,007 Welsh adults aged 16 years and above, 2751 (18.3%) reported they had been caring for a sick, disabled, or frail person. The carers tended to be between 40-74 years, female, had not obtained a bachelor's degree, with a body mass index>25, physically active, smokers, and living in indoor secondhand smoke households. People who lived in mid and western Wales tended to give care, compared with those who lived in southeast and north Wales. Carers with back pain experienced slight physical health and emotional problems, whereas carers without back pain experienced worse physical health and emotional problems, which could disrupt normal life.

CONCLUSION

Nearly one in five Welsh adults, with or without back pain, have provided care for other people. Future socioeconomic structure, health policy, and nursing programmes to reinvest in long-term care, such as a national psychiatric care initiative, should be encouraged, to lessen mental suffering alongside chronic pains and to optimise adult mental health and quality of life in all people, with or without back pain.