Burden of care amongst caregivers who are first degree relatives of patients with schizophrenia

Introduction Caring for a mentally ill family member is a challenging task. Caregivers who are first-degree relatives (FDR) are at a higher risk of experiencing the negative consequences of caregiving. This study was aimed at determining burden of care and its correlates in caregivers who are first-degree relatives of patients with schizophrenia. Methods A dyad of 255 patients and caregivers was recruited. A socio-demographic questionnaire was administered to both. The GHQ-12 was used to screen for psychiatric morbidity in the FDRs. Caregiver's burden was assessed with the Zarit Burden Interview. Patients' illness severity and level of functioning were assessed using the Brief Psychiatric Rating Scale and the Global Assessment of Functioning scales respectively. Results The mean ± SD age of caregivers and patients were 45.1 ±12.3 and 36.7 ±13.4 years respectively. About 49% of caregivers experienced high burden of care. Older caregiver's age (r = 0.179; p < 0.004) and greater illness severity (r = 0.332; p < 0.0001) in the patient had weak to moderate positive correlation with burden of care. Caregiver's burden also increased with poorer functioning of the patient (r = -0.467 p < 0.0001). Independent predictors of caregiver burden were low level of education of the caregiver (OR 2.45; 95% CI 1.27-4.73), psychiatric morbidity in the caregiver (OR 6.74; 95% CI 2.51-18.15) and poor patient functioning (OR 2.81; 95% CI 1.27-6.18). Conclusion Caregivers who are first-degree relatives of patients with schizophrenia experience varying degrees of burden of care during caregiving. Routine screening and early psychological intervention would help to ameliorate these negative consequences of caregiving.


Introduction
Schizophrenia is a chronic psychiatric disorder characterized by dysfunction in one or more areas of functioning; interpersonal relations, work or education, or self-care [1]. It ranks among the 5 th and 6 th leading contributors to global disease burden among males and females respectively [2]. It runs a chronic course, which is characterized, by remission and relapses leading to deterioration in social functioning, occupational functioning [3] and a loss in productivity [1,4]. The consequent economic impact of this disorder on both caregiver and care recipient is enormous. Direct and indirect costs arise from therapeutic interventions and loss of productivity respectively [1,5]. These costs overlap with emotional and social burden resulting from care to sufferers [4,5]. In some healthcare systems, especially in low and middle income countries, direct costs are also borne by caregivers. In most cases, direct cost, which is largely out-of-pocket finance for healthcare, is borne mostly by relatives of individuals in their communities [6][7][8][9]. Caregivers often alter their household schedules and lifestyle to accommodate the special needs of ill relatives [10]. This could exacerbate the burden of care they experience [10,11]. Burden of care has been categorized into objective and subjective burden [12]. Objective burden refers to outwardly quantifiable demands such as the financial cost of the illness, disruption of family routines, and patient's dependence on the family for both economic support and support with activities of daily living [13]. Subjective burden refers to the emotional response of the caregiver to the behavioural and social difficulties of the mentally ill [7]. Many patients with schizophrenia are mostly cared for in the communities by their relatives [14]. In Nigeria, these caregivers are mostly relatives who are likely to be mothers to the care recipients [15]. Care recipients are dependent majorly on their caregivers for their daily activities [14]. This causes restructuring of household schedules and disruption in family routines [10]. This contributes to increased burden of care. Caregivers of people with mental disorders are at risk of developing psychological distress due to increased caregiver burden [16,17]. Caregivers who are biological relatives of persons with schizophrenia have higher risk of developing mental disorders due to their genetic predisposition [15]. This study aimed to determine the burden of care and its correlates in caregivers who are first-degree relatives of patients with schizophrenia.

Methods
This cross-sectional study was conducted at the outpatient clinic of the Federal Neuro-Psychiatric Hospital (FNPH), Benin City, Edo State in Southern Nigeria. It is a tertiary government hospital that provides both in-patient and out-patient mental health services to the inhabitants of the state and its environs. The participants comprised of a 'dyad' of a first degree relative; who is the primary caregiver, and the patient with schizophrenia attending the outpatient clinic. A primary caregiver was defined as a first-degree relative and a non-professional, non-paid person who was mostly involved with the everyday care of the patient. He/she should also be very likely to respond to any request for special assistance at any time, if such a request was made by the patient [8,18]. A firstdegree relative could be a biological parent, a full sibling, or biological child of the patient. Caregivers who were aged 18 years and above, first-degree relatives and the primary caregivers of the patient were recruited. Caregivers who could not communicate in English or declined consent to participate in the study were

Results
Caregivers: The mean age (SD) of the caregivers was 45.1 (12.3) years. The caregivers were mostly married (61.6%) females (65.5%) with secondary level of education (33.3%) and were employed (83.1%). One hundred and sixty-seven (65.5 %) caregivers earned more than N10, 000 ($50) monthly. A majority of the caregivers live with the patient (93.3%), have been caring for the patient for more than 48 months (52.9%) and are solely responsible for payment of their treatment (51%) ( Table   1 and Table 2).

Discussion
We identified varying levels of caregiver burden among caregivers who are first-degree relatives. Nearly half of the caregivers reported significant burden (mild to severe burden). Although this agreed with previous findings of significant burden among caregivers [6-8, 19, 20], the rates were lower for our study. An explanation may be that first-degree relatives (FDRs) who are caregivers of the patients were sampled. These FDRs may view their caregiving role as an obligation hence, their reluctance to report negative experiences of caregiving. Our study found that caregiver's low level of education (i.e. secondary education and below) was a significant predictor of caregiver burden. This finding agrees with similar reports from previous studies [9,19,20]. Low educational attainment is associated with low income and socioeconomic status.
Caregivers with low educational status may be socially and economically disadvantaged. They may lack the financial capacity to meet up with the demanding needs of caregiving. In addition, lower educational attainment may negatively affect caregiver's knowledge and understanding of the illness. Poor psychosocial functioning of the patient was also an independent predictor of caregiver's burden. High burden of care was significantly associated with occurrence of psychiatric morbidity in caregivers. Generally, the association between psychiatric morbidity and caregiver burden have been previously reported [6,7,18,[23][24][25]. The caregiving experience is considered a chronic stressor which impacts negatively on the mental health of caregivers [26]. Chronic stress could cause physiological changes which ultimately lead to psychiatric morbidity [26]. On the other hand, caregivers who are FDRs, due to shared genetic makeup with the care recipient have greater vulnerability to develop psychiatric morbidity [27]. Caregivers with pre-existing psychiatric morbidity may experience greater burden or rate their perception of burden higher.

Conclusion
The relevance of this study is far reaching. Caregivers, who are firstdegree relatives of patients with schizophrenia, have significant burden of care, which are associated with presence of psychiatric morbidity in the caregivers themselves, the patient's poor functioning status and the educational status of the caregiver.  Caring for a relative with poorer psychosocial functioning also was a predictor of caregiver burden.

Competing interests
The authors declare no competing interests.

Acknowledgments
We thank the staff of Federal Neuropsychiatric Hospital, Uselu, Benin for their cooperation during the period of data collection. Table 1: Socio-demographics of caregivers and patients