Comparison of social adjustment in the caregivers of patients with schizophrenia and bipolar disorder: A hospital based study

There is limited information and research studies from India regarding social adjustment among the caregivers of patient with schizophrenia and bipolar disorder. The study was carried out to assess and compare the social adjustment among the caregivers of patients with schizophrenia and bipolar disorder. The present study was conducted on OPD level at Ranchi Institute of Neuropsychiatry &Allied Science (RINPAS). In this cross-sectional study caregivers of 60 patient who gave consent for their participation in the study and satisfy the inclusion & exclusion criteria in the age group 20-50 years were selected. There were caregivers of 30 bipolar and 30 schizophrenia patients in the study sample. Tools administered were socio-demographic and clinical data sheet and social adjustment inventory. Caregivers of schizophrenia patients obtained statistically significantly lower scores on two areas of social adjustment i.e. emotional adjustment and social maturity compared to families of patients with Bipolar affective disorder. Caregivers of schizophrenia patients have significantly lower social adjustment as compared to families of bipolar affective disorder patients.


Introduction
The institution of family exists in every human society. The world family has been taken over from the Roman word 'famulus', meaning a servant. Depending on the nature and severity of the sickness, the family is required to mobilize its internal and external resource to cope with the impending crisis. Family care and treatment are important predictors of successful coping with many diseases. Schizophrenia is the paradigmatic illness of psychiatry. The policy of deinstitutionalization has highlighted the role of family members as the primary sources of care giving for relative with schizophrenia. A noteworthy finding by Weidman et at., was that despite the apparent downfall of traditional family structure, over 60% of patient with long term schizophrenia live with at least one 'significant other' i.e. primary care giver. 1 Previous research studies conducted in Europe, the United States and Brazil revealed consistently impaired social adjustment in subjects with major psychiatric disorders is very common, particularly in subjects suffering from schizophrenia and bipolar disorders. [2][3][4][5] Adjustment is the reflection of human intelligence and it gives understanding about the healthy coping system, the individual is born with. Relatives of patients with schizophrenia employ a broad range of coping styles in response to behavioral change in patients. 6 Both emotionfocused and problem-focused coping lead to reappraisal of the stressful event i.e., the patient's illness. The lifetime emotional, social consequence experienced by individual with schizophrenia as well as affective disorder has significant efforts on their families. Families usually start with ignorance of the illness and the strange behavior is not recognized as illness but seen as an extrusion of normal personality or denied as presenting a problem. 7 Some relatives ask patient to own their behavior, seeing them as difficult or lazy. Such relative often have high expressed emotion rating. 8 Eventually the behavior reaches a threshold were the family can no longer cape. Family anxiety and fear increases markedly and they will seek help which may in turn antagonize the person seen as having the problem. Living with the established illness brings the realization that thing will never be as before, and that then has to be an adjustment to the actual living of functioning of the person with schizophrenia. There is sadness and mourning (bereavement) for the loss of the person they knew before the illness. 9 While a number of studies have studied the social adjustment of persons with mental illness, there is paucity of studies evaluating the social adjustment of families of patients with severe psychiatric disorders. In view of the above the present work was undertaken to assess and compare the social adjustment problems among the families having patient with schizophrenia and affective disorder.

Materials and Methods
The present study was conducted on OPD level at Ranchi Institute of Neuro Psychiatry and Allied Science (RINPAS). The proposal for the study was submitted to the Institutional ethical committee and the study was started after obtaining approval. All the subjects gave written informed consent. Sample Based on purposive sampling technique a sample of 60 subjects were included in sample. The study was conducted on 30 caregivers of schizophrenia and 30 affective disorder respectively between the age range of 20-50 years who were selected from outpatient unit of RINPAS Kanke, Ranchi. Duration of living of care giver with patient was minimum 5 years. Patients were diagnosed as schizophrenia and affective disorder according to ICD-10 DCR criteria at the time of their admission into the hospital. Only patient for outpatient unit coming for follow up were included who had minimum one year's duration of illness.

Tools Sociodemographic and clinical data sheet
This self-made consisted of questions to obtain personal information from the subjects on such theme as age, address, gender, education, religion, caste, marital status, tribal/non-tribal, education, monthly income and occupation and clinical details of the patients.

Social Adjustment Inventory (SAI)
The SAI developed by R.C. Deva was utilized for the assessment of Social Adjustment of the caregivers of subjects with schizophrenia and bipolar disorders. The inventory consists of a total of 100 statements with a forced choice 'yes' and 'no' alternatives to answer. The responses of respondent to the questions of the inventory was done according to the scoring key of the inventory. The inventory provides scores on Emotional Adjustment, and Social Maturity. High score on the inventory implies good Social Adjustment and low score as poor Social Adjustment. The inventory has yielded satisfactory reliability and validity indices. The test retest reliability after a period of two month was 0.91. The emotional and social adjustment scales of this inventory were validated against the corresponding scale of Saxena's 'Vyaktitva Parakh Prasnavali'. 10 Procedure Caregivers were interviewed and then assessed with the help of sociodemographic data sheet and Social adjustment inventory. The scale was scored as per instructions in the test manual. There were two area of adjustmentemotional adjustment score and the social maturity score.

Statistical analysis
Chi-square was used to find out the significant difference between adjustment problem of caregivers of schizophrenia and affective disorder.

Result
The caregivers of schizophrenia and bipolar affective disorder patients were well matched (Table 1).   The schizophrenic group, 16.6% of caregivers have good and 83.3% have poor social maturity score whereas in the bipolar affective disorder group, 40% of caregivers have good and 60% have poor social maturity score. The difference was statistically significant (Table 3).

Discussion
In psychiatry, the family denotes a group of individuals who live together during important phases of their lifetime and are bound to each other by biological relationship and /or social, psychological relationship. One main reason for mental health professionals for shifting their attention and concentrating on families is that they understood the crucial role that the family members could play in providing primary and after case to psychiatric patients who returned home as a result of deinstitutionalization. About one third to one quarter chronically mentally ill persons live with their patients. The fact that so many families who are actively assisting their ill relative on a day to day basis has led same authors to suggest that it is only the family and not the traditional formal treatment system that has assured primary responsibility for management and care of the mentally ill. As most of the family studies of psychiatric patients are etiological, the view that relatives may have a deleterious influence on the course and outcome of illness is reflected in the behavior of many mental health professionals in the clinic, who may give on impression of blaming them or regarding them only as exploitable sources of information.
In the schizophrenia group 50% of family member have good and 50% have poor emotional adjustment whereas in the bipolar affective disorder group 80% of family members have good and 20% have poor emotional adjustment. Similarly in the schizophrenia group, 16.6% of family members have good and 25% have poor social maturity score whereas in the bipolar affective disorder group 40% of family members have food and 18% have poor social maturity score. Finding of the present study are similar to that of Boye et al 11 who reported that both male and female schizophrenia have significantly poor adjustment in emotional and social maturity parameter.
Schizophrenia is an extremely stigmatizing disease associated with negative social consequences of shame, increased family burden, and inadequate support for care and rehabilitation. 12 The unpredictable nature of the disorder, partial improvement with treatment and continuous cost leads to anger and frustration in caregivers and family members. Caregivers and other family members are not sure of the right way of help due to ignorance about the causes, treatment, factors related to relapse, aftercare and rehabilitation. Even though the management of social disability among schizophrenic patients in the community is an important part of treatment, facilities for the same are unavailable. 13 Families in India are generally supportive to the mentally ill persons and tolerate and accept the person with mental disorders at least at the beginning of their illness. Relatives of patients with schizophrenia experience more burden and distress due to the patient's symptoms, social and occupational dysfunction. Psychoeducation of the family members and involving them in the management of the patients will go a long way in improving their attitude to the patients, and help them cope with their sorrows and problems. [14][15] Conclusion Caregivers of schizophrenia patients have significantly lower social adjustment in the areas of emotional adjustment and social maturity as compared to families of bipolar affective disorder patients.