Approximately 40% of the sample screened positive for depressive symptoms and 50% were dissatisfied with life circumstances. None of these caregivers so far has had the opportunity to have a formal therapy session for themselves as the primary focus was the patient. Yet, when specifically questioned 43% admitted that they also needed professional help to overcome their mental strain. This unidentified burden not only has a deleterious effect on caregivers but also on patients they are caring for. It also has an impact on the rest of the family if they are the sole breadwinners being responsible for the financial upkeep of the household.
The significant associations for being depressed among caregivers were, spending more time with the patient (above the group average), being assaulted by the patient, interruption to work, disputes with children and other relations and the subjective feeling of increased psychological burden. It is noted that other demographic factors that were thought to play a role such as level of education, amount of debt, disease characteristics of the patient and substance use of caregivers, were not associated with symptoms of depression. Adverse factors affecting the immediate environment of the caregiver and his/her emotional milieu on a daily basis were better predictors of depression. Conflicts with close family members, close association with the patient and being assaulted by the patient carry a heavier impact on the day-today mental status of the caregiver than the other issues mentioned above. It must also be noted that the caregiver may not be the sole breadwinner of the family and hence the effect of not being employed or being in debt may not be a direct concern. He or she may have adequate support from other family members and this will ‘dilute’ the impact of such financial adversities on the caregiver.
Lesser satisfaction with life was also associated with factors more likely to affect the caregiver’s immediate living environment (disputes with relations and spending more time with the patient). However being in debt and level of education was also significantly associated with having a low SWLS scores. The nature of questions asked in CES-D concentrates on the current situation in caregiver’s life. However, the questions in SWLS require the caregiver to look back and take a reflection of his/her entire life. Therefore factors such as being in debt (which is the net balance of life’s finances so far for a family or an individual) or inability to secure a better education and hence better opportunities in life may conspicuously stand out in SWLS scores.
The modified caregiver strain index assesses the extent of caregiver strain and like the CES-D concentrates more on the current disturbances to the caregiver’s life. Therefore the responses and significant associations observed paralleled those observed for CES-D scores, except the fact that being in debt, was a significant association for worse caregiver strain index scores.
We could not find any similar studies conducted in Sri Lanka in published literature. Literature on caregiver strain on schizophrenia and bipolar affective disorder is surprisingly sparse in the international indexing services but the conclusions from existing studies show this phenomenon to be of significant importance [12, 13]. Some of our findings are in keeping with the findings of studies overseas while certain other observations are not. For example, it is a well established fact that interruption to work or termination of work significantly increases caregiver strain . In many studies quoted in this article, gender of caregivers did not surface as a significant predictive factor of increased strain which was the same observation in our study. In a study of predictive validity of the resource deterioration model on recognizing depression among mothers of schizophrenic patients in the USA, coping resources and physical health of caregivers had value in the model but not social stressors like economic strain and burden of care . Regarding contradictory findings, a study that assessed the caregivers’ state of health with the General Health Questionnaire (GHQ), concluded that the time spent with patient was irrelevant to the burden of care and mental strain of the caregiver. The strain of the caregivers’ marital relationship was more predictive of the mental strain .
Regarding the caregiver burden of bipolar affective disorder patients, the stress on caregivers on various aspects of patient behaviour (problem behaviours, role dysfunction and disturbance to household routine) was in the range of 50-80% in a study in the USA . Those who had a higher burden were more likely to have depressive symptoms as well .
As mentioned previously, the caregiver strain is influenced by a variety of cultural and sociological modifiers that is specific to each community. It also depends on the support and coping strategies available to individuals. Therefore findings of one community cannot be applied to another directly. This is especially true when comparing developed and developing nations given the wide disparity of support services and treatment strategies available. This fact may explain certain disparities observed in our results and other studies of which the majority are from the USA. The key significance of this study is that we have identified several associations for depression and increased caregiver strain of principal caregivers of a subset of mentally ill patients in Sri Lanka that can be used to screen others in the same setting. This also adds to the very small number of papers available on the topic from developing countries. The most important point that stands out here is that the caregivers own discontent of their mental state is a significant factor associated with underlying depression or caregiver strain. Simply asking the question ‘do you think you are mentally run down and need professional help ?’ will be helpful in identifying a target population to screen (to increase pretest probability) rather than haphazardly applying the questionnaires in their entirety to all.