The measurement of burden of care in serious mental illness: a qualitative review

"Everyone means well but the one person who's really going to go to bat" - experiences and perspectives of substitute decision makers in caring for their loved ones with serious mental illness

In the era of on-going efforts to empower persons with mental illness to be independent decision makers as informed by the United Nations' Convention on the Rights of Persons with Disability (CRPD), family members acting as substitute decision makers (SDM) for people suffering from disabling serious mental illness (SMI) remain an integral part of the medical-legal system in psychiatric care in many parts of the world, including Canada; yet their experiences and perspectives are rarely studied. This explorative qualitative study examines the lived experiences and reflections of 14 family member SDMs in Toronto, Canada. Five key themes related to being SDM emerged: 1) Varied subjective understanding of the responsibility and authority of the SDM role; 2) Varied role demands and impact on SDMs' lives; 3) Challenges in dealing with the mental health system; 4) Leveraging decision making status to promote patient care; and 5) SDM role impact on family relationships. The need to improve SDM understanding of their role, acknowledging their value and care-taker burden, finding a balance for their involvement, and improving their support in efforts to enhance care for the patients are discussed.

Experiences of Family Burden in Caring for the Severely Mentally Ill in a Foreign Land: A Qualitative Study of Chinese Immigrant Families in Toronto, Canada

There is a relative dearth of qualitative studies on the actual experiences of families caring for members suffering from serious mental illness, and even less is known about disadvantaged ethnic minority immigrant families. This explorative qualitative study examines the burden experienced by 15 family members of Chinese immigrant background in Toronto, Canada. Six common themes emerged from the study: 1) significant worries about not being able to take care of ill members in the future; 2) on-going strain and changed family life; 3) pervasive social stigma, discrimination and lack of resources; 4) general appreciation of Canadian health and welfare systems and opportunities; 5) cultural factors and beliefs uniquely shape families' support and caring commitment; and 6) families find various ways to cope and help themselves. Opportunities for improved care delivery based on these understandings are discussed.

The Burnout Dyad: A Collaborative Approach for Including Patients in a Model of Provider Burnout

Both patients and providers in the United States (US) suffer from burnout, which can impact the clinical relationship and quality of care. Among providers, burnout is a state of exhaustion including heightened depersonalization; among patients, burnout can negatively affect clinical outcomes. More than half of clinical providers in the United States suffer from burnout; less is known about the magnitude and prevalence among patients. Understanding patient burnout will improve our recognition of treatment barriers, understanding of patient-provider communication, and perceived quality of care. The purpose of the 2019 Stanford University MedicineX Burnout Workgroup was to use a collaborative approach to expand on the National Academy of Medicine (NAM) Wellness and Resilience Model, which does not currently include the patient as an influential member of the care team potentially experiencing burnout. This collaboration among patients, physicians, students, caregivers, technologists, and researchers used a convenience sample of conference attendees, broken into three focus groups to (1) provide an expanded definition of burnout that includes patients' perspectives, (2) analyze the NAM burnout model for inclusion of the patient experience, and (3) define a care experience that includes both patients and providers. The design of this workgroup was informed by Everyone Included, a model that recognizes and rejects hierarchical traditions in clinical practice. This approach allowed for the creation of a safe space for the exchange of knowledge between the various stakeholders. The resulting inclusive conceptual model, The Burnout Dyad, describes a cocreated care experience informed by both patient and provider characteristics.

Sleep Quality in Caregivers of Older Patients with Schizophrenia Spectrum and Bipolar Disorders: A Case-Control Study

OBJECTIVES

Prior literature has documented the global burden of serious mental illnesses. The present study aimed to compare the sleep quality in caregivers of older patients with schizophrenia spectrum and bipolar disorders with control participants who did not serve as caregivers.

METHODS

We performed a case-controlled, cross-sectional study among family caregivers of older patients with psychotic disorders in Razi Hospital, Tunisia. Subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index Scale (PSQI).

RESULTS

Fifty caregivers of older patients (≥ 60 years) with schizophrenia spectrum and bipolar disorders, and 50 matched controls were enrolled. The three sub-dimensions of the PSQI, namely subjective sleep quality, sleep duration, and sleep efficiency, as well as overall PSQI scores, were worse for caregiver participants. Hierarchical multiple regression analyses predicting PSQI scores revealed that caregivers' age and marital status were the only significant predictors in the final model.

CONCLUSIONS

Older adults with severe mental disorders constitute a vulnerable population which generates a significant burden of care, and impacts their caregivers' subjective sleep quality.

CLINICAL IMPLICATIONS

Family interventions, including sleep interventions, should be considered as an integral component of treatment for serious mental illnesses. When promoting sleep quality, older and single caregivers should be targeted.

Australian mental health caregiver burden: a smallest space analysis

OBJECTIVES

To explore Australian mental health carers' prioritisation of key elements of caregiving and establish the extent to which particular issues contribute to carer burden.

DESIGN

Cross-sectional survey.

SETTING

All Australian States and Territories.

PARTICIPANTS

Responses were received from 231 Australian mental health caregivers.

MAIN OUTCOME MEASURES

The Involvement Evaluation Questionnaire was used to assess caregiver burden.

RESULTS

Smallest space analysis identified three distinct regions, which we conceptualise as: 1) promoting the safety and health of mental health consumers; 2) impact of caring on caregivers' personal lives and 3) enabling daily living functional recovery of mental health consumers. The analysis demonstrates that carers are most concerned with enabling daily living functional recovery, for which the mean value was considerably higher than the personal impact and promoting safety and health regions. In terms of the individual questionnaire items, the issues of most importance are assisting with self-care, worrying about consumers' future, finances and general health, encouraging consumer involvement in activities and concerns over the treatment consumers are receiving.

CONCLUSION

Caregiving often came at significant personal cost. The burden that results from caring for mental health consumers could perhaps be alleviated through the expansion of psychiatric disability services, increasing government financial support and providing tailored psychosocial interventions that meet the needs of families.

Supporting a friend, housemate or partner with mental health difficulties: The student experience

AIMS

When experiencing mental health difficulties, university students turn to their friends for support. This study assessed the consequences of caregiving among a university sample, identifying predictors of caregiving burden among students.

METHODS

A total of 79 students with experience of supporting a friend with mental health difficulties were recruited through a UK student mental health charity to complete an online survey. Alongside qualitative data, the online survey used the Experience of Caregiving Inventory and the Involvement Evaluation Questionnaire as measures of the consequences of caregiving.

RESULTS

Students supporting friends, housemates or partners were found to experience significant consequences of caregiving. Frequency of face-to-face contact and duration of illness predicted more negative consequences of caregiving, but these relationships were not straightforward. The presence and intensity of professional support did not influence the experience of caregiving.

CONCLUSIONS

The study suggests that the impact of supporting friends with mental health difficulties is not insubstantial for students. Broadening the network of informal social support may help improve the experience for students supporting a friend, but currently, contact with professional services appears to have a limited effect.

Positive and negative impacts of schizophrenia on family caregivers: a systematic review and qualitative meta-summary

PURPOSE

Schizophrenia places a heavy burden on the individual with the disorder, as well as on his or her family; this burden continues over the long course of the disease. This study aimed to provide an overview of the positive and negative impacts of schizophrenia on family caregivers.

METHODS

From April to June 2017, two investigators conducted a systematic review and meta-summary of studies obtained from five electronic databases and the footnotes and citations of eligible studies. Qualitative studies that explored the experiences of family caregivers of individuals with schizophrenia were included. Study findings published between 1993 and 2017 were extracted and synthesised using narrative and summative approaches.

RESULTS

After the removal of duplicates, independent reviewers screened 864 records. Subsequently, 46 full-text articles were assessed for eligibility and 23 papers were included in the synthesis. Negative impacts identified were traumatic experiences, loss of expectation of life and health, lack of personal and social resources, uncertainty and unpredictability, family disruption, conflict in interpersonal relationships, difficulty in understanding, and stigma and heredity. Meanwhile, the positive impacts identified were family solidarity, admiration, affirmation, affection, compassion, learning knowledge and skills, self-confidence, personal growth, and appreciation.

CONCLUSIONS

Analysis of the studies suggested that family members of individuals with schizophrenia face a series of traumatic situations during the course of the illness. Their subsequent experiences can be conceptualised as a continuous circle of caregiving, in which the positive impacts can be centrally positioned within the negative impacts.

Quality of life in caregivers of a family member with serious mental illness: Evidence from China

PURPOSE

To evaluate the quality of life (QoL) and social support among family caregivers of a family member with a mental illness and to identify factors associated with the QoL.

METHODS

This is a cross-sectional study, where participants were recruited and independently interviewed using a questionnaire, consisting of demographic characteristics, the Medical Outcome Survey SF-36 form, and social support rating scales. Multiple stepwise regression analysis was used to analyse the factors related to QoL.

RESULTS

181 family caregivers were recruited in Shandong province, China. On a composite QoL score, family caregivers perceived that their QoL was poor (68.3), especially in the aspects of role-physical (61.3), role-emotional (57.6) and mental health (63.0). We also found family caregivers received low social support, especially in objective support and utilization of social support. Patient's illness state, care time, financial burden and objective support were significantly correlated to caregivers' QoL in the physical component score (PCS). Patient's illness state, patient's marital status, family monthly income, caregiver's knowledge about the illness, caregivers coordinating caring, life and work, subjective support received and utility of support were significantly associated with caregivers' QoL in the mental component score (MCS).

CONCLUSIONS

Social support had a significant correlation with caregivers' QoL. Caregivers should be encouraged to request assistance from other family members and friends in providing care, especially when caregivers are unemployed or long-time carers. Mental health education campaigns and helping families to maintain and enhance a supportive social network may provide useful means to improve caregivers' QoL.

Sobrecarga familiar, apoyo social y salud comunitaria en cuidadores de personas con trastorno mental grave

RESUMEN Objetivo Identificar el nivel de sobrecarga de los cuidadores y analizar los factores asociados con el cuidado familiar en salud mental. Método Se realizó un estudio descriptivo transversal realizado entre los meses de enero y julio del año 2016, en el que se evalúa una muestra de cuidadores de siete dispositivos públicos y una asociación de familiares y pacientes identificando la sobrecarga de los mismos y los factores que contribuyen a reducir estos niveles, a través del instrumento Zarit Burden Inventor y . El estudio se llevó a cabo de acuerdo a las recomendaciones de los comités de ética de las instituciones participantes. Resultados Participaron 107 cuidadores. Las principales aportaciones refieren que la participación activa del cuidador en dinámicas asociativas, la asistencia a actividades psicoeducativas y la vinculación territorial a áreas metropolitanas con recursos comunitarios, disminuyen el nivel de sobrecarga del cuidador. Conclusión Finalmente, destaca la importancia y responsabilidad de la enfermería comunitaria a efectos de prevenir los niveles de sobrecarga e incrementar los de salud; además, se realizan una serie de propuestas en la línea de favorecer redes de apoyo social, combinar tratamientos e incrementar los programas de salud pública en contacto con la comunidad.

Psychological interventions for caregivers of people with bipolar disorder: A systematic review and meta-analysis

AIMS

Clinical guidelines recommend that psychological interventions be offered to caregivers of people with bipolar disorder. However, there is little clarity about the efficacy of such interventions. This review examined the efficacy of psychological interventions in improving caregiver-focused outcomes, including burden, psychological symptoms and knowledge.

METHOD

A systematic search for controlled trials was conducted using a combination of electronic database searches (PsycINFO, MEDLINE, and CENTRAL), and hand searches. Risk of bias was assessed using the Cochrane Collaboration tool. Outcomes were meta-analysed using Review Manager (RevMan).

RESULTS

Nine studies met inclusion criteria. All meta-analyses compared psychoeducation to a control. At post-treatment there was a large effect of psychoeducation on burden (g = -0.8, 95% CI: -1.32, -0.27). However, there was high heterogeneity, confidence intervals were wide, and the effect was not maintained at follow-up. The apparent effect of psychoeducation on psychological symptoms was driven by a single outlying study. There was a very large effect on knowledge at post-treatment (g = 2.60, 95% CI: 1.39, 3.82) and follow-up (g = 2.41, 95% CI: 0.85, 3.98).

LIMITATIONS

There was considerable diversity in study methodology and quality. The number of included studies and sample sizes were small.

CONCLUSIONS

This review provides tentative meta-analytic evidence for the efficacy of psychoeducation in improving caregiver burden at post-treatment, and knowledge at post-treatment and follow-up. Services could consider offering psychoeducation as part of a multi-disciplinary package of care. However, more methodologically rigorous research is needed before clinical recommendations can be made with confidence.

Perceived Burden and Quality of Life in Chinese Caregivers of People With Serious Mental Illness: A Comparison Cross-Sectional Survey

PURPOSE

The aim of this study was to investigate perceived caregiver burden and quality of life (QOL) among Chinese family caregivers for people with serious mental illness (SMI).

DESIGN AND METHODS

This is a cross-sectional study design. Participants were recruited and independently interviewed using the Chinese version of the World Health Organization Quality of Life-Brief Form, Hospital Anxiety and Depression Scale, Social Support Rating Scale, and Family Burden Interview Schedule as outcome measures.

FINDINGS

In this study, 363 family caregivers were recruited. This study found that caregivers in Guangzhou perceived significantly higher levels of burden than did family caregivers in Hong Kong (all p values <.001). Weekly hours of contact with patients; subjective support; and subdomains of physical, psychological, and environmental QOL were significant predictors of perceived overall caregiver burden. Education levels, depressive symptoms, objective support, and objective caregiver burden significantly predicted caregivers' QOL.

PRACTICE IMPLICATIONS

Study findings suggest there is a need for developing and implementing effective intervention strategies to reduce caregiver burden and improve caregivers' QOL. Health policy makers should provide relevant resources, such as financial assistance with care for family caregivers, as it is important that the health policy fully recognizes the role of family caregivers as a healthcare resource in caring for people with SMI.

Influence of Religion on Later Burden and Health of New Black and White Caregivers

Objective: We assessed the relationship between positive aspects of religiosity and reduced stress in caregivers, and negative aspects of religiosity and increased caregiver burden. Method: Using data from the Biopsychosocial Religion and Health Study, we performed multiple linear regression analysis on 584 caregivers. Results: Mental health, but not physical health, was predicted by caregiver burden. Caregivers who viewed God as loving and not controlling and felt a sense of community with their church family had less burden. Caregivers who engaged in negative religious coping had a greater decline in mental health than those who saw God as loving and not controlling and who gave emotional support to others. Discussion: Some aspects of religion appear to play an important role in alleviating the mental stresses of being a caregiver.

Collaboration in crisis: Carer perspectives on police and mental health professional's responses to mental health crises

For many situations involving a mental health crisis, carers (e.g. family or friends) are present and either attempt to help the person overcome the crisis or request assistance from professional services (e.g. mental health or police). Comparatively, little research has explored how carers experience the crisis, the professional response and how the nature of the response, in turn, impacts carers. The current study was conducted to explore these issues during individual interviews with nine carers who had previous contact with police and mental health services during a crisis response. Collected data described the definition and perceived impact of a mental health crisis for carers, how carers had experienced a crisis response from police and mental health services, and how the professional response had impacted on carers. Of importance was the finding that carers were often themselves traumatized by witnessing or being involved in the crisis, however, were rarely offered direct education or support to help them cope or prevent future crises. A number of carers described a reluctance to request assistance from professional services due to previous poor experiences. This highlighted the importance of implementing strategies to deliver more timely, respectful, specialist and collaborative crisis responses to improve carer and consumer outcomes.

Life adversity is associated with smoking relapse after a quit attempt

Multiple cross-sectional studies have linked adverse childhood events and adult adversities to current smoking, lifetime smoking, and former smoking. To date, however, there have been no direct observational studies assessing the influence of adversities on smoking relapse. We prospectively followed 123 participants, 86 of whom were habitual smokers, from pre-quit ad libitum smoking to four weeks post-quit. Thirty-seven non-smokers were also tested in parallel as a comparison group. Subjects provided biological samples for confirmation of abstinence status and self-report history of adversities such as abuse, neglect, family dysfunction, incarceration, and child-parent separation. They also completed mood and smoking withdrawal symptom measures. The results indicated that within non-smokers and smokers who relapsed within the first month of a quit attempt, but not abstainers, females had significantly higher adversity scores than males. Cigarette craving, which was independent from depressive affect, increased for low adversity participants, but not those with no adversity nor high adversity. These results demonstrate that sex and relapse status interact to predict adversity and that craving for nicotine may be an important additional mediator of relapse. These results add further support to the previous cross-sectional evidence of an adversity and smoking relationship. Further studies to clarify how adversity complicates smoking cessation and impacts smoking behaviors are warranted.

A randomized trial to assess the efficacy of a psychoeducational intervention on caregiver burden in schizophrenia

BACKGROUND

Patient's relatives usually care for patients with schizophrenia, and as informal caregivers they experience negative consequences. The aim of the EDUCA-III trial is to test the efficacy of a psychoeducational intervention program (PIP) versus standard care to reduce the caregiver burden at post-intervention (4 months), and at follow-up (8 months).

METHOD

A two-arm, evaluator blind, multicentre, randomized controlled trial. The PIP group had 12 weekly group sessions. The control intervention group had the usual support and standard care. Primary outcomes were change scores since baseline on the Zarit Burden Interview (ZBI) and the Involvement Evaluation Questionnaire (IEQ).

RESULTS

One hundred and nine caregivers were randomized to PIP and 114 to control condition from 23 research sites. The decrease of ZBI scores was significantly higher on the PIP arm at 4 months (mean difference [MD]=-4.33; 95% CI -7.96, -0.71), and at 8 months (MD=-4.46; 95% CI -7.79, -1.13). There were no significant decreases in the IEQ scores (MD at 4 months=-2.80; 95% CI -6.27, 0.67; MD at 8 months=-2.85; 95% CI -6.51, 0.81).

CONCLUSIONS

The PIP condition seems to reduce caregiver burden.

TRIAL REGISTRATION

ISRCTN32545295.

Caregiver Positive and Negative Appraisals: Effects of the National Alliance on Mental Illness Family-to-Family Intervention

The 3-month-long Family-to-Family intervention (FTF) has been shown to increase empowerment, knowledge, and coping and to reduce distress among caregivers of people with serious mental illness. We sought to determine the influence of FTF on caregivers' appraisal of their caregiving experience. Family members of individuals with mental illness who sought enrollment in FTF (n = 318) were randomly assigned to FTF or a waitlist condition. Positive and negative appraisals were measured using the Experiences of Caregiving Inventory at baseline and 3 months later; 259 participants completed both assessments. Regression analyses found significant increases in positive appraisal but no significant decreases in negative appraisals for those in the FTF condition. In the context of overall benefits from taking FTF, these relationships reflect the FTF curriculum's emphasis on positive coping (e.g., strength and empowerment) and the potential value of strategies that help caregivers increase positive appraisal.

A Journey of Discovery: Experiences of Carers of People with Mental Illness Seeking Diagnosis and Treatment for Their Relative

This study explores the experiences of informal carers of people with mental illness in an Australian mental health service. A qualitative descriptive approach was used with data collected via focus group interviews with a purposive sample of 19 carers. Data analysis revealed two major themes: (a) "Something is not right" and (b) "Now we have a diagnosis." The carers noticed that there was something wrong with their relative before they received a diagnosis but were often hesitant to engage Mental Health services. Carers have trouble understanding if the problems they are witnessing are part of normal development, contemporary culture, or are symptoms of mental illness. Fear of stigma remains a barrier to accessing services and early diagnosis. Findings suggest a need to target support for informal carers in the period prior to and leading to the establishment of a mental health diagnosis.

The use of the Burden Assessment Scale with families of a pediatric population

The emotional, financial and social impact on caregivers of those with pediatric psychiatric, emotional and behavioral disorders has been poorly documented. This study sought to begin to remedy this by determining the utility of the Burden Assessment Scale (BAS) with this population. 300 parents seeking services within a major Canadian city were interviewed using the BAS and a follow up questionnaire on the clarity, comprehensiveness and acceptability of the BAS. The BAS was clear, acceptable and comprehensive for >80% of participants. Factor analysis revealed four factors compared to the original five factors found with adults. The BAS had a utility with this population and would be a valuable addition to standard information gathered but use of the total score only is recommended.

New trends in assessing the outcomes of mental health interventions

Assessing the outcomes of interventions in mental health care is both important and challenging. The aim of this paper is to advance the field of outcomes research by proposing a taxonomy of the decisions that clinicians and researchers need to consider when evaluating outcomes. Our taxonomy has eight components, framed as decisions: Whose outcome will be considered? Which scientific stage is being investigated? What outcome domain(s) matter? What level of assessment will be used? Will clinical and/or recovery outcomes be assessed? Whose perspective will be considered? Will deficits and/or strengths be the focus? Will invariant or individualized measures be preferred? We propose a future focus on understanding what matters most to people using mental health services, and on the use of measures rated by service users as the primary approach to evaluating outcome.