The International Journal of Psychosocial Rehabilitation

Depressive Symptoms and Family Functioning in the Caregivers of Recently Hospitalized Patients with Chronic/ Recurrent Mood Disorders.

Alison M. Heru M.D.
Brown University School of Medicine

Christine E. Ryan Ph.D.
Brown University School of Medicine

Heru, A., & Ryan, C.  (2002)  Depressive Symptoms and Family Functioning in the
 Caregivers of Recently Hospitalized Patients with Chronic/ Recurrent Mood
 Disorders.   International Journal of Psychosocial Rehabilitation. 7, 53-60.

Alison M. Heru, M.D., Butler Hospital, Brown University School of Medicine, 345 Blackstone Boulevard, Providence, Rhode Island 02906.  Tel.: 401-455-6314  Fax: 401-455-6309.   E/mail address:
Christine Ryan, Ph.D. Rhode Island Hospital, 593 Eddy Street, Providence, Rhode Island 02903
Background. Our aim was to determine the relationship between family dysfunction and depression in caregivers of patients with chronic / recurrent mood disorders.
Method. 16 caregivers of patients with chronic / recurrent mood disorderswere recruited during their relativeís in-patient psychiatric stay and completed self-reports instruments including the CESD, FAD and measures of burden and reward.
Results. Caregivers were mostly male (56%) and spouses (69%). Despite reporting significant amounts of strain and burden, caregivers felt that care giving was rewarding. 72% of the caregivers scored positively for depressive symptoms. Caregivers who reported poor family functioning had dysfunction in all areas of family functioning and were significantly more likely to report depressive symptoms.
Conclusions. Family functioning and depression are closely associated in the caregivers of patients with chronic / recurrent mood disorders. The experience of reward and burden are not mutually exclusive.
Historically, studies of the families of psychiatric patients have focused on outcome measures for patients. For schizophrenia, successful family intervention decreases mean cost of patient care by 27% (1) and reduces relapse rates and improves quality of life (2). For patients with bipolar disorder, high levels of caregiver burden have been shown to predict subsequent adverse clinical outcomes in bipolar disorder patients (3). Multifamily group therapy treatment for bipolar patients and their families reduces patient relapse rates and improves patient quality of life (4). Families of patients with affective disorders experience high levels of caregiver burden (5). Moreover, there is evidence that a large number of caregivers have rates of depressive symptoms as high as 38% to 60% (6,7). These family members often go untreated. Thus there is evidence that a systemic view that includes family members of the patient may be warranted for the best outcome for both the patient and family members.

It is time therefore, to assess family caregivers and intervene if necessary, with the aim of improving the health of the caregiver and the patient. This study will examine the relationship between family functioning and depression in caregivers of patients with chronic/recurrent mood disorders.

Several research tools have been used to assess family functioning in families with a relative suffering from chronic psychiatric illness. One of the oldest tools measures "expressed emotion" (EE), the attitude that a relative has towards a family member with a psychiatric impairment. Families that demonstrate high levels of criticism, hostility or emotional over-involvement are known as high EE families (8). Families with high expressed emotion have been shown to be a "significant and robust" predictor of relapse in psychiatric illnesses (2). Expressed emotion, however, looks at only one aspect of family functioning whereas a more comprehensive measure is often preferable. One model of assessment and therapy, McMaster Model of Family Functioning (9) and the Problem Centered Systems Therapy of the Family (10) is ideally suited to assess a broad range of family functions. This model assesses several dimensions of family functioning such as affective involvement, affective responsiveness, roles, communication, behavior control and problem solving. Other measures of family functioning that may be applicable in the assessment of caregivers, include the Family Hardiness Index (11) that measures family transition crises and adaptation for acute and long term stressors and the self report Family Inventory (12) that allows measurement of family functioning across several domains, such as competence, cohesion, leadership and emotional expressiveness.

Caregiver coping strategies are linked to caregiver burden although the strength of this association is not clear (13,14). However, healthier coping strategies such as problem-focused coping strategies, which include positive communication and increased social involvement, may be associated with less burden (15). Family caregivers of bipolar patients more often use healthier strategies than caregivers of patients with schizophrenia. Possible reasons include improved inter-episodic functioning and the fact that caregivers of bipolar patients tend to be spouses rather than parents. Thus the family may enjoy more adult problem solving rather than regressing to a parent-child relationship.

In spouses of psychiatric patients suffering from depression, anxiety or schizophrenia, female spouses have prevalence rates for all psychiatric illnesses of 1.8-2.5 times that of male spouses and twice the rate of depressive illnesses (16). Many caregiver variables have been reported as being significantly related to depression in caregivers, such as the general stress of coping with chronic psychiatric illness (17) and the grief associated with having a spouse with chronic psychiatric illness (18).

Several studies have tried to evaluate the links between family functioning and depression. Assortative mating has been suggested as a factor resulting in the higher incidence of depression among spouses of patients with psychiatric illness (19,20). Longitudinal studies of depression and family functioning show that depressed patients with persistent family dysfunction had poorer clinical outcome at 12 months (21). The relationship between poor family functioning and depression is certainly present, but it is unclear if the family dysfunction maintains the depression or if the depression maintains the family dysfunction.

We report the results of a study that looked specifically at links between caregiver burden, family functioning and depressive symptomatology in families of patients with chronic/recurrent mood disorders. Our aim was to determine the extent to which family dysfunction and depression were related and to identify how these variables were related to the perception of caregiver burden and reward.

16 caregivers of patients with chronic/recurrent mood disorders were approached during their relativeís in-patient psychiatric stay by a trained researcher who obtained informed consent and recruited them into the study. Approval for the study was obtained from the Hospital Institutional Review Board prior to the study beginning. Chronic/recurrent mood disorders were defined by chart review, as having had 3 or more episodes in the past two years, or by being continuously symptomatic for five years. Patients with concurrent axis I, axis II and axis III were included although primary substance abuse diagnoses were excluded. If caregivers scored positively on the screening for depressive symptoms or family dysfunction, they were informed by telephone and offered referral for further assessment.

Basic socio-demographic information was collected as well as information on social support and other care giving roles. Family functioning was assessed using the Family Assessment Device (22) and a visual analog scale. The Caregiver Strain scale (CSI) (23) and visual analogue scales measured the strains and burdens of care giving. The family memberís perception of the patientís functional level was measured with the Family Memberís Activities of Daily Living Questionnaire (24). The CES-D, Center for Epidemiological Studies Depression Scale, (25), measured the caregiverís level of depressive symptoms and the Satisfaction scale, a sub-scale of the care giving instrument by Schofield et al. (26), measured the caregiverís level of satisfaction in caregiving.

Characteristics of the sample were described using univariate statistics. Bivariate analyses comparing gender, diagnoses, length of time care giving, and depression included chi-square analyses for categorical factors and t-tests for continuous variables. Correlation analyses were used to examine how family functioning was related to depression, strain, burden, and rewards.

Caregivers were more likely to be male (56%) and spouses (69%). The mean age of caregivers and patients was 55 and 53 years respectively. Despite reporting strain and burden, caregivers felt care giving to be rewarding. Caregivers reported that the rewards of care giving (7.4 sd 3.3) outweighed the burden (4.2 sd 3.2).
Table 1. Selected characteristics of caregivers of recently hospitalized chronic / recurrent mood disorder patients (N=16).
Caregiver gender
Caregiver role
Caregiver age
Patient age
Caregiver scores.
Strain (a)
VAS-Burden (a)
Rankin-Burden (a)
VAS-Rewardb (b)
(a)= higher score is worse
(b)= higher score is better
Family Functioning. 
Problem solving 
Affective Responsiveness
Affective Involvement 
Behavior Control 
General Functioning 
Unhealthy scores underlined.

Using a cut-off score of 19 on the CES-D, 72% of the caregivers scored positively for depressive symptoms. When we used >21 as a cut-off, 56% scored positively for depressive symptoms. Caregivers who reported poor family functioning were more likely to meet report depressive symptoms (Table 2).
Table 2. Relationship between depression1 and family functioning2 (N=16)
Family Functioning
Good  Poor x2 p
Depressed 2 (28.6) 8 (72.7)
Non-depressed 5 (71.4) 3 (27.3) 3.38 0.066
 Depression measured by a CES-D score of > 21
 Measured by the General Functioning score on the Family Assessment Device (FAD)

Comparisons between the depressed and non-depressed caregivers show significant differences in several areas of family functioning (Table 3). The depressed caregivers reported dysfunction in all areas of family functioning.
Table 3. Depression and dimensions of family functioning1 (N=16)
Depressed  Non-depressed
Mean (sd) Mean (sd)
Problem Solving  2.40 (.44) 1.92 (.25)
Communication  2.68 (.43) 2.21 (.35) 
Roles  2.69 (.37) 2.10 (.25)
Affective Involvement 2.41 (.39)  1.98 (.39)
Affective Responsiveness 2.41 (.55) 1.98 (.31) 
Behavior Control  2.01 (.35) 1.93 (.33)
General Functioning  2.56 (.51) 1.75 (.30)
 Family functioning measured by the Family Assessment Device. 
.Unhealthy scores are underlined.

This study of 16 caregivers of patients with chronic/recurrent mood disorders explored the relationship between caregiver burden and reward, family functioning and depressive symptomatology. The majority of these caregivers are spouses and males. We believe that the higher number of male caregivers in our sample is a reflection of the higher incidence of major depression in women and our population of chronic/recurrent mood disorders. Although caregivers reported significant satisfaction in caregiving despite reports of burden and strain, they also reported significant impairment in several areas of family functioning as well as high levels of depressive symptoms.

Firstly, caregivers reported a significant level of satisfaction in caregiving, despite reports of burden and strain. Caregiversí comments focused on the level of affective or emotional involvement and the gratification in knowing that oneís help is appreciated. Caregivers stated that they enjoyed giving back to a spouse who had taken care of them in earlier years and that their care ensured that the spouse was getting their needs met in the best way.

Secondly, caregivers reported difficulties in almost all areas of family functioning. When the sample was divided into depressed and non-depressed caregivers, the depressed caregivers accounted for almost all of the family dysfunction. Role difficulties in this sample of predominantly men may indicate difficulty with the care giving role or housekeeping roles, which are seen as traditional female roles. Communication difficulties and poor affective involvement may reflect intimacy and closeness difficulties when a spouse or family member is mentally ill.

Thirdly, 72% of the caregivers reported depressive symptoms and the most severe family dysfunction. Thus, the correlation between depressive symptoms and family dysfunction is supported. The CES-D is the most widely used self-report screening tool in community studies and its psychometric properties have been shown to be strong in many populations (27). However, a criticism of the CES-D is that the relationship between self-reported symptoms of depression on the CES-D and the diagnosis of a depressive illness may only be modest (28). Scores of 16 and above are generally believed to indicate individuals at risk for clinical depression. We chose a cut off of 21 to be sure that depressive symptoms are problematic and to improve sensitivity (29).

Although caregivers reported depressive symptoms and family dysfunction, they declined treatment referral, stating that their problems were situational or that they did not have the time to seek treatment. Studies of caregivers of patients with chronic psychiatric illnesses support this finding; few caregivers seek out help for themselves even though the evidence for the benefits of treatment is high. Treatment refusal rates with intervention studies of caregivers of are reported at 25-50 % of caregivers refusing treatment (30,31,32). Reasons suggested for treatment refusal included: "no acute need" at the time of enrollment, perception of blame by the mental health services, denial of illness and lack of understanding of rationale for intervention. Knowledge of other families struggling with the same problems and increased emotional support has been found to increase a familyís sense of competence and produce better functioning for the patient (33). Family membersí quality of life has also been shown to improve with services that support, education and involve family members (34).

This study supports the relationship between depressive symptoms and family dysfunction. Overall, caregivers reported more reward than burden and reward. The experience of burden does not preclude the experience of reward. Caregivers with poor family functioning accounted for most of the caregivers with depressive symptoms. Causality is unclear but may involve many factors such as assortative mating, pre-existing depression or family dysfunction as well as a response to the caregiving situation. It is of concern that caregivers themselves were not receptive to treatment interventions after discharge and it is therefore important to try to engage these families during the time of the patientís hospitalization.

Limitations of the study include the small sample size, a selective recruitment from a hospital setting, which reflects a crisis time in the life of a caregiver. Although the use of self-report questionnaires could be considered a limitation, they are cost efficient and reflect caregiver perceptions, the focus of our question. The homogeneity of the sample suggests little ethnic variety, which may be important as there is evidence that different ethnic groups respond to the demands of care giving differently (35).

The next step in our research involves the longitudinal study of caregivers, using psychiatric and family assessment / intervention for those caregivers with depressive symptoms and family dysfunction. We also plan on assessing the effects of caregiver intervention on the well being of the identified patients, by monitoring readmission rates and quality of life indices.

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