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The relationships between depression … and caregiving

Pao-Feng Tsai¹ and Mary M Jirovec^2
1College of Nursing, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
²College of Nursing, Wayne State University, Detroit, Michigan, USA

BMC Nursing 2005, 4:3 doi:10.1186/1472-6955-4-3

The complete electronic version of this article can be found online at: http://www.biomedcentral.com/1472-6955/4/3

© 2005 Tsai and Jirovec; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background

Many caregivers with chronically ill relatives suffer from depression. However, the relationship of depression to other outcomes of chronic caregiving remains unclear. This study tested a hypothesized model which proposed that hours of care, stressful life events, social support, age and gender would predict caregivers' outcomes through perceived caregiver stress. Depression was expected to mediate the relationship between perceived stress and outcomes of chronic caregiving (physical function, self-esteem, and marital satisfaction).

Background

It is estimated that 31-55% of caregivers of chronically ill elderly relatives experience depression [1], and depression is likely to be one of the first [2] and most enduring psychological outcomes for caregivers [3,4]. Caregivers' depression scores have been found to be substantially higher than those of the general population [1,5,6], and higher levels of caregiving stress have been related to greater depression [7,8] and to more depressive symptoms in caregivers [9].

Factors that may be related to stress and depression in caregivers include hours of care, stressful life events, social support, age, and gender. Studies have found that hours of care were significantly related to caregivers' anxiety/depression and somatic symptoms [10,11], and to their emotional and physical strain [12]. Though stressful life events have been associated with both psychological wellbeing [13,14] and physical symptoms among the general population [14], no studies have examined stressful life events in combination with caregiving stress. Stressful life events might have additional impact on caregivers' health other than chronic caregiving.

Social support may enhance the ability of the individual to cope with events or change the individual's cognitive appraisal of events [15]. Quayhagen and Quayhagen found that caregivers who reported needing more social support had lower well-being scores than other caregivers [16]. In other studies, low social support predicted higher perceived burden [7], and adverse social contacts were associated with increased stress [17].

Age has been shown to have indirect effects on depression through its influence on perceived stress, the coping process, and perceived efficacy [18]. Younger caregivers experience more distress than older caregivers [19,20], and they express more subjective burden than older caregivers [21]. Gender has also been shown to have effects on depression. Female caregivers report more distress [1,22] and higher psychiatric morbidity [5] than male caregivers.

Tsai et al. have suggested that stress and depression are emotional aspects of coping mechanisms and depression is the outcome of perceived caregiver stress [23]. Stress has in turn been shown to be the strongest predictor of depression in caregivers [24]. Though depression has been associated with caregivers' physical health [25,26], the data on physical health are less consistent than on psychological health. Some studies have found that caregivers had poorer self-reported health than non-caregivers [27-29], more chronic illnesses [30], and lower immune function [31]; and they used more health care services and took more prescriptions [27]. Convinsky et al. reported that depression was associated with physical function dependence. Caregivers with functional dependence has 2.53-fold chance to be depressed as compared to those who with functional independence [32]. Other studies, however, have found that caregivers did not use more medical services [33] or rate their physical health as less satisfactory than the general population [6]. Further, as Schulz, Visintainer and Willamson point out, even though some studies have suggested possible effects of caregiving on physical health, the evidence is confounded by sampling bias, inadequacy of measurements, and subjective appraisals [34].

Although the associations between depression and self-esteem and marital satisfaction have been examined extensively, only a few studies have been conducted in the context of caregiving. Caregivers have been shown to have lower self-esteem [35], and this has been associated with depressive symptoms [10]. Caregivers who had higher self-esteem experienced less depression [36]. In one study, depressed caregivers were more likely to experience less marital satisfaction [37]. Also, high levels of marital conflict were associated with high levels of depression in adult daughter caregivers [38]. Finally, spousal caregivers reporting low marital cohesion and satisfaction had more depressive symptoms [39].

A recently developed Theory of Caregiver Stress [23] based on theoretical propositions from the Roy adaptation model [40] suggests that depression is the mediator between perceived stress and self-esteem and marital satisfaction. However, the relationships of depression to other outcomes of caregiving, such as physical function, self-esteem and marital satisfaction, remain unclear. The research reported here therefore explored these relationships. We proposed that hours of care would be the primary source of caregiver stress. Stressful life events, social support, age, and gender were antecedent variables and expected to influence caregivers' outcomes through caregiver stress. Depression was conceptualized as a mediator between caregiver stress and other outcomes of chronic caregiving (physical function, self-esteem, and marital satisfaction). Thus, a high level of stress was expected to lead to a high level of depression, which in turn would result in lower levels of physical function, self-esteem, and marital satisfaction.

Conclusion

In spite of its limitations, the study shows the importance of psychological mediators in the care of a chronically ill relative. The question of how caregivers manage to avoid adverse outcomes or why some caregivers are at risk for adverse outcomes can be answered in part by understanding the role of depression. Clearly, to avoid adverse outcomes, clinical interventions should target caregivers who are experiencing depression.