The correlation of caregiving burden with depression, anxiety, and stress among caregivers of people with schizophrenia

Background: Schizophrenia is a severe mental disorder that requires collaborative approach from the health care provider, family, and the society in its management. Adequate support from the family of people with schizophrenia plays a significant role in their recovery. However, providing support to these patients might become a significant burden among caregiver that it might induce the occurrence of stress, mood changes, and ansiety. This research aimed to determine the correlation between caregiver burden and the mental problems that might be experienced by caregivers of people with schizophrenia. Patients and Methods: This qualitative research employed a cross sectional analytic design. Samples were obtained consecutively in June and July 2018. The questionnaires used were the 22 item Zarit Burden Interview (ZBI) and the 42 item Depression, Anxiety and Stress Scale (DASS-42). Result: A number of 69 subjects participated. The caregiving burden demonstrated strong positive significantly correlations with problems including depression, anxiety, and stress (r=0.618, r=0.694, r=0.808, respectively ; all p<0.001). Conclusion: There is a relationship between caregiving burden and depression, anxiety, and stress on caregivers of people with schizophrenia (PWS) in Sanglah Hospital in Denpasar.


Introduction
Schizophrenia is characterized by loss of touch to reality, distortion or disorganization of mental capacity, and the capacity of the individual to recognize reality, communicate, and form relationships with others.1 Characteristics of schizophrenia tend to be associated with chronic impairment and the characteristics of psychotic episodes that could have an impact not only on the patient but also on the people around them, especially those closest. These closest people usually involved as caregivers for patients and help patients.2 Family involvement in patients with schizophrenia will appear very clear in those who experience long-term impairment, but their involvement in the early stages of the disease is also essential. Providing family intervention at an early stage for both patient and caregiver is essential to help relatives to improve their understanding of the disease, addressing disrupted thought and emotion, reducing negative assessment, and prevent high emotional expression to the patient.3 Caregivers need special attention so that they can overcome difficulties and support the recovery of the patient. So far, not much is known of any research on caregivers of patients with schizophrenia in Indonesia. At Psychiatry Polyclinic of Sanglah General Hospital (RSUP) itself, from 3,536 the number of visits during 2017, there were about 850 visits by patients with the diagnosis of schizophrenia. So far, the burden of care on caregivers who accompany patients with schizophrenia and the possible relation with psychiatric problems such as depression, anxiety, and stress they might experience is not known, but it is vital to know in order to be intervened. Based on these considerations, the researcher has an interest in conducting this study.

Material and Methods
This study uses a quantitative analytical design with a cross-sectional analytic approach. This research was conducted in the Depart-

Result
Sixty-nine respondents met the inclusion criteria for the sample used in this study. The mean age of the study subjects is 45 years old, with a standard deviation of 12.5 years. The characteristics of caregivers are presented in Table 1. Table 2 shows the characteristics of the patients treated. The average age of the patients of this study subjects is 35.9 years old.

Table 1. Characteristics of the study subjects (caregivers).
Patients tend to be younger than their caregivers. Based on the total treatment duration, 32 people (46.4%) less than three years, and 37 people (53.6%) is equal to 3 years. The number of psychotic episodes distributed one time as many as 25 people (36.2%) and most often distributed as much as five times with four people (5.8%).    Table 4. Correlation between caregiving burden score and DASS-42. Table 4 shows a strong positive correlation between the score of caregiving burden and depression score, the higher the caregiving burden the higher the level of depression. Caregiving burden score and anxiety scores obtained correlation coefficient of 0.694 and p <0.001, which means there is a strong positive correlation between score of caregiving burden and score of anxiety. Likewise, the correlation between score of caregiving burden and stress scores even higher correlation coefficient of 0.808 and p <0.001, which means there is a very strong positive correlation between the score of caregiving burden and stress.   Tables 6 and 7 show the distribution of anxiety level based on the level of caregiving burden. At none/almost none level of caregiving burden none experience anxiety or 100% normal. While at mild caregiving burden some starts experiencing mild anxiety with 3 people (7.7%) and moderate enxiety with 6 people (15.4%).

Discussion
The results show that the age of caregivers in schizophrenic patients is mostly adulthood and productive age group between 25 years-44 years with a total of 33 respondents (47.8%). That age is mature enough to make decisions, able to think rationally, and to control emotions. This age is also considered mature enough in life and mental experience to take care of a family member who has schizophrenia.4 The sex majority of caregivers in this study is male, with 36 respondents (52.2%). This is not following the majority of Indonesian people who usually put women to take care of the household, including caring for a sick family member. This is due to women's social role and hormonal factors. Women are more dominant primary caregivers compared to men. This study found as many as 56.5% of respondents with mild care treatment burden, and five respondents with moderate caregiving burden, the rest with no caregiving burden. Most respondents experienced caregiving burden. Respondents as caregivers are a primary source of support and often manage the economy, medical assistance, and supervision for everyday tasks.
Meeting the physical and psychological needs of the PWS, spending 6-9 hours per day to provide care and attention.5 Only a small part have depression, anxiety, and stress. This is because caregivers can take care the patients with the motivation and sense of responsibility to perform the duty or simply because there is a desire to do good. Normally this can happen in families that show good relationships and flexibility, used to open communication, and is able to use more resources in the community to solve the problem.6 In this study, there's correlation between the score of caregiving burden and DASS-42. Strong positive correlation between the score of caregiving burden and depression scores showed that the higher the caregiving burden, the higher the level of depression. Likewise, there is a strong positive correlation between the score of caregiving burden and score of anxiety. The higher the score caregiving burden, the higher the anxiety score. In contrast to the correlation between the score of caregiving burden and stress score is even a very strong positive correlation between the score of caregiving burden and stress score. The relationship between caregiving burden and DASS-42 also considered other variables that may be associated with DASS-42. For example, the number of recurrence psychotic episodes has meaningful relationship. With higher psychotic episodes, the caregiving burden for caregivers will increase.
The benefits of this research is the need of more specific treatment for families who take care of people with schizophrenia. In outpatient setting, beside management of outpatient patients, intervention of medical personnel to the caregiver should also be done. These The weakness of this study is that component of caregiving burden was assessed at one time so it couldn't be seen in depth. More in-depth observation study is needed to determine caregiving burden experienced by families who care for people with schizophrenia.

Conclusion
Most caregivers of people with schizophrenia in Sanglah Hospital are categorized as having caregiving burden. From this study we can conclude that there is a relationship between caregiving burden and depression, anxiety, and stress on caregivers of people with schizophrenia (PWS) in Sanglah Hospital in Denpasar. Under these conditions, psychosocial interventions to families who care for people with schizophrenia is an important thing. Support for caregivers also need to be emphasized in the treatment of schizophrenic patients while not ignoring the mental health problems of caregivers.