Soc Psychiatry Psychiatr Epidemiol (2007) 42:923930

DOI 10.1007/s00127-007-0242-8

ORIGINAL PAPER

Rakesh K. Chadda Tej B. Singh Kalyan K. Ganguly

Caregiver burden and coping

A prospective study of relationship between burden and coping in caregivers of patients with schizophrenia and bipolar affective disorder

Received: 27 January 2007 / Accepted: 20 July 2007 / Published online: 13 August 2007

j Abstract Introduction: Caregivers of patients of schizophrenia and bipolar affective disorder (BAD) experience considerable burden while caring their patients. They develop different coping strategies to deal with this burden. Longitudinal studies are required to assess the relationship between caregiver burden and coping. Aim: The present study was conducted to assess relationship between burden and coping in caregivers of clinically stable patients with schizophrenia and BAD. Method: One hundred patients each of schizophrenia and BAD attending a psychiatric outpatient setting and their caregivers were followed up for a period of 6 months. Burden and coping strategies were assessed in the caregivers at baseline, and after 3 and 6 months using the Burden Assessment Schedule (BAS) and Ways of Coping Checklist - Hindi Adaptation (WCC - HA). Results: Burden remained stable over 6 months and was comparable in the two groups of caregivers. Caregivers from both the groups were found to use problem focused coping strategies more often than seek social support and avoidance strategies. Scores on avoidance type of coping showed a positive correlation with the total burden scores and a number of burden factors. Conclusion: Caregivers of patients of schizophrenia and BAD face similar levels of burden
Prof. R.K. Chadda (&) All India Institute of Medical Sciences Ansari Nagar New Delhi 110029, India Tel.: +91-11/2659-3236 or -3245 Fax: +91-11/2658-9787 or -8663 E-Mail: drrakeshchadda@hotmail.com T.B. Singh Dept. of Clinical Psychology Institute of Human Behaviour & Allied Sciences Delhi, India K.K. Ganguly Indian Council of Medical Research New Delhi, India

and use similar types of coping methods to deal with it. Relationship between caregiver burden and coping is quite complex. j Key words burden coping schizophrenia bipolar disorder India

Introduction
Patients suffering from schizophrenia and bipolar affective disorder (BAD) impose considerable burden on their caregivers [4, 6, 14, 23]. The burden includes multiple responsibilities such as nancial costs, physical care of the patient and compromises on the personal freedom and leisure activities [22, 25, 27, 31], and has been reported to affect the course of illness [24, 26, 28]. Severity of illness and symptom characteristics are important predictors of burden [28, 33, 34], with disorganized behaviour [34] being especially associated with higher levels of burden. The caregivers develop different kinds of coping strategies to deal with the burden which include nding a reasonable solution, looking for support from friends or other near ones, or trying to avoid the situation by indulging in activities like smoking or substance abuse [13, 20, 30]. Caregivers experience higher levels of burden when they have limited coping resources [1, 10]. Reduction in the perceived burden has been reported in the caregivers who adapt less emotion focused coping strategies [13]. The earlier studies on caregiver burden and coping were cross sectional in nature [3, 12, 14, 20, 29]. The cross sectional studies provide limited information about the inuence of various social and clinical factors on burden, and whether burden remains stable over the course of illness or changes as per the circumstances [13, 28]. Caregiver burden has been reported to be closely interconnected with the course of

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the patients illness [8, 10] and is likely to improve, as the patient responds to treatment. Since burden is likely to change over the course of illness [8, 10], longitudinal studies are needed to understand the burden characteristics and factors affecting it. Similarly, comprehensive longitudinal assessment of the coping strategies used by the caregivers is required so that any maladaptive methods can be identied and dealt with appropriate interventions. Most of the initial studies on burden of psychiatric illnesses were in schizophrenia [6, 31]. Later studies conducted on caregivers of BAD patients have reported similar level of caregiver burden [11, 23]. There have been only a few studies, which have compared burden and coping in the caregivers of patients with schizophrenia and BAD [2, 3, 19, 29]. The earlier studies reported similar pattern of burden in caregivers of patients with schizophrenia and BAD [3], though those caring for schizophrenia were found to perceive higher burden as compared to that in BAD group [3, 29]. Some differences were also observed in the coping strategies used by the caregivers from the two groups of patients [2, 19]. Caregivers from the BAD group use the problem focused strategies more often, whereas schizophrenia caregivers have been reported to resort more often to the emotion focused (or maladaptive) strategies [2]. The same group of authors in a later study reported more frequent use of coercive coping and avoidant behaviour strategies (i.e. smoking, drinking, taking pills etc.) by caregivers of patients of schizophrenia [19]. There is a lack of longitudinal comparative studies on burden and coping in schizophrenia and BAD, the two most disabling psychiatric disorders besides depression. Longitudinal and comparative studies may help in understanding the complex relationship between the caregiver burden and coping. The present study assessed burden and coping strategies in a group of caregivers of patients with schizophrenia and BAD in a prospective design and analyzed the relationship between various components of the caregiver burden and coping strategies.

patients should have been ill for a minimum period of one year, and clinically stable for a minimum period of 3 months before the study. Clinical stability was dened as no major changes in medication and no hospitalization in the 3 months preceding the intake. Criteria of clinical stability was included to control for the effects of orid illness on burden, since the orid symptoms are likely to impose higher burden, which would come down as the symptoms get controlled with treatment. Patients with any associated chronic physical illness, co morbid substance use disorder and having any living family member suffering from psychiatric illness staying in the same household were excluded. To be included in the study, the caregivers needed to be consenting adults with no history of mental illness, and should have been caring for the patient for at least one year. Written informed consent was taken from the caregivers and/ or the patients, as appropriate. The study was approved by the Institutes ethics committee. About 1,000 patients were screened over a period of one year for the study, out of whom, 305 (150 of schizophrenia and 155 of BAD) met the study criteria. All the patients and caregivers consented for the study. The patients continued to attend the regular outpatient services during the period of study. Some of them, who missed their follow up, were reminded by letters or telephonically by the research team to come for assessment. In a few cases, the research team also made home visits to carry out the assessment. Since it had been planned to have 200 completed cases, the follow up assessments were stopped, once the target was achieved. However, the patients continued to receive the usual outpatient care on further follow up in the service. j Measures Burden in the caregivers was assessed by Burden Assessment Schedule (BAS) [32]. BAS is a 40 item structured instrument in English, which assesses both objective as well as subjective burden experienced by the caregivers of chronic mentally ill patients. The items are rated on a 3 point scale, marked 13 with the responses being not at all, to some extent, and very much. The instrument has been developed and standardized on Indian population. It is administered by the researcher. BAS has been reported to have a good inter rater reliability (j 0.80) and satisfactory face validity in terms of the relevance of the items in measuring caregiver burden [32]. The 40 items have been grouped into 9 factors: spouse related, physical and mental health, external support, caregivers routine, support of patient, taking responsibility, other relations, patients behaviour and caregivers strategy. Factors of spouse related burden, physical and mental health, and other relations refer to the effects of caregiving on the sexual and marital relationship, physical and mental health of the caregiver, and relationship with other family members and friends respectively. Items in the factor of caregivers routine refer to the effect of caregiving role on the caregivers day to day activities. Appreciation and support, which the caregiver gets from other family members or friends on account of caregiving role, form the external support factor. Effect of the patients problematic behaviour on family functioning is included in the patients behaviour factor. The burden factors of taking responsibility, support of patient, and caregiver strategies relate to meeting various needs of the patients, generating nances, planning for future requirements, seeking support from friends and increased work load. There is some overlap between various factors, burden being a complex construct. Coping strategies used by the caregivers were assessed by Ways of Coping Checklist-Hindi Adaptation (WCC-HA), an instrument adapted from the Ways of Coping Checklist of Folkman and Lazarus [5]. The original instrument has 28 items, each item rated on a ve point likert scale from never to all the time. Caregivers are asked how often they have used the listed strategies in the previous 3 months to deal with the problems while being in contact with their patient. Scazufca and Kuipers [30] have used a modied 13 item version of the checklist in relatives of people with schizophrenia. The modied

Material and methods

j Sample The study was conducted from November 2001 to October 2003 in psychiatric outpatient clinic at the Institute of Human Behaviour & Allied Sciences, Delhi (India). A large majority of the patients attending the service suffer from psychotic disorders including schizophrenia, BAD and others, and most of them are accompanied by their family members, who are also the caregivers. Patients of schizophrenia and BAD in outpatient care and their caregivers were screened for the study by the research staff (two psychologists and a social scientist) under supervision of RKC. Inclusion criteria for the patients included age 1550 years, diagnosis of schizophrenia or BAD on International Classication of Diseases, Diagnostic Criteria of Research (ICD DCR) [35], and availability of family members or caregivers for assessment. The

925 version was translated to Hindi and tested in 30 caregivers for its suitability in the local population. This required some minor modications. The modied version (WCC-HA) was administered by the researchers to the caregivers to assess their coping strategies. The items in the checklist refer to three categories of coping strategies; problem focused, seek social support, and avoidance. Coping strategies in the problem solving group include assessing the problem, deliberating on various actions which could be taken to reduce it, choosing the activities after a careful thought which would be helpful, devising an action plan and working out the solution. Seek social support methods refer to taking advice and support from specialists, friends or relations; sharing ones feelings with others, and meeting other people with similar problems. Avoidance strategies in the list include resorting to smoking, acting out, wishing a miracle could happen and solve the problem, and avoiding meeting others. Psychopathology in the patients was assessed by the 18 item version of Brief Psychiatric Rating Scale (BPRS) [7, 21]. j Assessments In the rst step the research staff was familiarized with the assessment instruments. Thirty patients and their caregivers (12 of schizophrenia and 18 of BPAD) were included in the pilot phase. No major problem was faced in administration of questionnaires except in case of WCCHA, which needed some minor modications. Patients and caregivers fullling the inclusion and exclusion criteria were assessed by the research staff under supervision of RKC and TBS. Intake started in January 2002 and the follow up assessments nished in July 2003. Burden and coping strategies of the caregivers, and psychopathology in the patients were assessed at intake, and at 3 and 6 months follow up on various measures as described earlier. j Interventions The patients continued to get the routine outpatient care in the hospital. The patients and caregivers were also offered psychoeducation sessions to improve the coping skills in the caregivers and treatment adherence in the patients. The sessions were conducted by the research staff with inputs from authors. In the sessions, the participants attended a brief presentation about prevalence, clinical presentation, common misconceptions and available treatments of severe psychiatric illnesses including schizophrenia and BAD using display materials. The patients and caregivers were also given copies of some educational material on schizophrenia and BAD in Hindi. A total of 22 sessions were organized at a frequency of twice a month. Each session was attended by 45 patients and 68 caregivers. It was aimed to cover all the patients and caregivers for educational sessions, but only 80 patients and 120 caregivers could attend the sessions. j Analysis The data was tabulated as per frequency distribution across different sociodemographic groups. ANOVA and t test statistics were used to assess the signicance of differences in scores on BAS, WCC-HA and BPRS between the two case groups and at different assessments. Correlation between various burden factors and coping strategies was studied using Pearsons product moment correlation.

of which 100 patients and 100 caregivers each of schizophrenia and BAD completed the 6 months follow up. There were no signicant differences between the cases and drop outs on various sociodemographic and clinical characteristics. Thirty six percent of patients with schizophrenia were in the age group 1530, compared to 44% of the BAD group. About 20% of patients in both groups were above 40. Seventy ve percent of schizophrenia patients and 65% of those of BAD were males. Sixty ve percent of the patients in both groups were married. Nearly one third of the patients had received up to 5 years of formal education, about half had completed schooling, and 16% had completed graduation. More than half of the patients lived in joint families. More than 80 percent of the patients were working. Nineteen percent of schizophrenia patients and 26% of those of BAD group were housewives. Agriculture, clerical jobs and small scale business were the other common professions of the patients. More than 85% patients belonged to low socioeconomic group with a monthly income of less than 2,000 Indian rupees. The two groups were comparable on most of the variables, except that 40% of the BAD subjects came from rural background, compared to just 13% of the schizophrenia group (P < 0.001). The two caregiver groups were comparable across various sociodemographic variables. About one fourth of the caregivers each in both the case groups were in the age groups below 25 and above 50. Fifty eight percent of the BAD caregivers and 49% of those from the schizophrenia group were males. About half of them had received only up to 5 years of formal education. Parents and spouses formed three-fourth of the caregivers. More than 90% of the caregivers were living in the same household as their patients and were having a daily contact with the patients. Most of the caregivers were living with their patients for more than 10 years. Patients belonging to the schizophrenia and BAD groups had similar levels of severity of psychopathology as measured on BPRS. Over the 6 months follow up, there was a signicant reduction in mean BPRS scores from 32.88 to 28.26 in schizophrenia group (P = 0.006), and from 31.05 to 27.03 in BAD group (P = 0.013).

j Burden characteristics
Caregivers from the both the groups had similar pattern of burden as revealed in scores on various factors of BAS. The caregivers scored high specically on two of the burden factors: taking responsibility, and physical and mental health. Total score on BAS was compared across different sociodemographic groups. No signicant differences emerged in total burden scores across various sociodemographic variables including age, sex, education, family type, income, occupation and residence, though on a few variables, signicant differences were

Results
j Sample characteristics
The initial intake consisted of 305 patients and their caregivers (150 of schizophrenia and 155 of BAD), out

926 Table 1 Scores on various burden factors in caregivers of BPAD and schizophrenia patients at baseline and follow up (N = 200) Sub items of BAS BPAD (N = 100) Mean SD 3.68 3.23 3.91 3.48 3.93 3.48 10.73 3.35 10.90 3.57 10.50 3.48 7.66 2.68 7.45 2.74 7.20 2.70 5.72 1.71 5.71 1.82 5.38 1.80 4.42 1.29 4.19 1.36 4.20 1.16 10.04 2.65 9.47 2.87 8.66 2.86* 4.10 1.34 4.11 1.45 3.86 1.17 5.91 2.00 5.98 2.32 5.67 2.22 6.73 2.07 6.49 2.37 5.96 2.11 3.86 1.35 3.69 1.44 3.53 1.37 62.85 13.49 61.90 15.75 58.89 15.58 Schizophrenia (N = 100) Mean SD 4.11 3.47 3.94 3.32 4.14 3.56 10.48 3.29 10.66 3.52 10.30 3.53 7.41 2.80 7.42 2.92 7.44 2.81 5.60 1.65 5.24 1.66 5.40 1.57 4.11 1.14 4.26 1.40 4.50 1.12 10.20 2.33 9.53 2.82 8.90 3.02** 3.93 1.35 3.88 1.13 4.02 1.42 5.66 1.97 5.45 1.71 5.70 2.09 6.80 1.83 6.48 2.24 6.27 2.33 3.12 1.22 3.35 1.36 3.52 1.55 61.41 12.68 60.21 13.63 60.19 14.51 Table 2 Scores on WCC-HA in caregivers of BAD and schizophrenia patients Scores on WCC-HA BAD (N = 100) Mean SD Schizophrenia (N = 100) Mean SD 9.62 2.66 10.32 2.74 10.54 3.14 8.06 2.55 7.80 2.44 7.99 2.08 10.39 2.25 10.17 2.22 10.58 2.20

Spouse related Baseline 3 months 6 months Physical and mental health Baseline 3 months 6 months External support Baseline 3 months 6 months Caregivers routine Baseline 3 months 6 months Support of patient Baseline 3 months 6 months Taking responsibility Baseline 3 months 6 months Other relations Baseline 3 months 6 months Patients behaviour Baseline 3 months 6 months Caregivers strategy Baseline 3 months 6 months Others Baseline 3 months 6 months BASTotal Baseline 3 months 6 months

Problem focused (max. score 15) Baseline 9.89 2.55 3 months 10.39 2.67 6 months 10.10 2.73 Seek social support (max. score 20) Baseline 8.29 2.75 3 months 8.29 2.40 6 months 8.01 2.51 Avoidance baseline (max. score 30) Baseline 10.65 2.52 3 months 10.88 2.53 6 months 10.54 2.40

j Coping strategies
Caregivers from the two groups had comparable scores on the WCC-HA on various coping strategies both at the baseline as well as on follow up (Table 2). On the subscale of problem focused strategies, the caregivers achieved about two-third of the maximum possible score (subjects scoring 3 or 4 on most of the items), whereas the mean score on the seek social support strategies was about 40% of the maximum score (subjects scoring 13 on various items), and was further less at just one third (subjects scoring 12 on most of the items) in the avoidance strategies subgroup. Thus, the caregivers were using the problem focused and seek social support types of coping strategies more often than the avoidance strategies. No signicant differences were observed in the use of different coping strategies across various sociodemographic groups. Scores on various coping strategies did not show any signicant change on follow up assessments in both the groups.

j Relationship between burden and coping

Table 3 shows the correlational statistics of the relationship between various burden factors and the coping strategies. Use of avoidance coping strategies showed a positive correlation with many of the burden factors like physical and mental health, caregivers routine, taking responsibility, other relations, patients behaviour, and caregivers strategy, and also with the total burden score in both schizophrenia as well as the BAD case groups. No consistent correlations were observed between burden and the problem focused strategies in both the case groups. Seek social support coping strategies showed a positive correlation with the burden factors of physical and mental health in both the case groups and with the burden factors of caregivers routine and the patients behaviour in only the BAD group. There were also some other signicant correlations between some of the burden factors and the coping strategies at one of

* F value 5.58, P = 0.004, ** F value 6.13, P = 0.002

seen at one of the three assessments. In the BAD group, caregivers of the married patients perceived higher burden than those of the unmarried patients at all the three assessments. In the schizophrenia groups this difference was signicant at the baseline assessment, but not after 3 and 6 months. Total burden scores as well as scores on various burden factors did not show any signicant differences between the two caregiver groups both at baseline as well as on follow up (Table 1). No significant change in burden scores was observed on follow up, except in the burden factor of taking responsibility, where the score declined signicantly in caregivers of both the groups over the 6 months follow up (P 0.004 in schizophrenia and 0.002 in BAD).

927 Table 3 Correlation between scores on burden factors and coping strategies in schizophrenia and BAD patients Burden factors Months Coping factors Problem focused Schiz Spouse related Physical and mental health External support Caregivers routine Support of patient Taking responsi-blity Other relations Patients behaviour Caregivers strategy Others BAS-T (Total score) 0 3 6 0 3 6 0 3 6 0 3 6 0 3 6 0 3 6 0 3 6 0 3 6 0 3 6 0 3 6 0 3 6 )0.02 )0.17 )0.29** )0.02 )0.21* )0.12 )0.32** )0.16 )0.02 )0.10 )0.25* )0.12 )0.18 )0.15 )0.00 )0.19 )0.11 0.17 0.04 )0.09 0.13 0.05 )0.12 )0.01 )0.16 )0.18 0.07 0.05 )0.09 0.12 )0.15 )0.29** )0.09 BAD )0.19 )0.17 )0.06 )0.04 0.07 0.17 )0.29** )0.1 )0.16 )0.02 )0.08 0.12 )0.07 )0.13 0.05 0.06 )0.1 0.09 )0.08 )0.08 0.16 0.07 0.05 0.20* )0.1 )0.21* )0.05 0.03 )0.01 0.15 )0.12 )0.14 0.07 Seeking social support Schiz )0.05 )0.12 )0.01 0.28** 0.21* 0.20* )0.06 )0.06 )0.04 0.03 0.14 0.08 )0.05 )0.04 )0.14 0.02 0 0.04 0.27** 0.16 0.01 0.2 0.18 0.19 )0.05 0.06 0.03 0.22* 0.14 0.07 0.12 0.1 0.27** BAD 0.02 )0.07 0.11 0.38** 0.30** 0.32** )0.16 )0.25* )0.11 0.26** 0.21* 0.22* )0.15 )0.19 0.18 0.07 0.03 0.02 0.17 0.05 0.13 0.38** 0.37** 0.28** )0.05 0.01 0.03 0.18 0.09 0.23* 0.19 0.1 0.17 Avoidance Schiz 0.15 0.02 )0.01 0.46** 0.51** 0.50** 0.06 0.13 0.12 0.37** 0.32** 0.37** 0.07 0.20* 0.16 0.25* 0.28** 0.37** 0.22* 0.42** 0.36** 0.46** 0.53** 0.48** 0.25* 0.46** 0.42** 0.31** 0.36** 0.27** 0.44** 0.52** 0.48** BAD 0.24* 0.18 0.16 0.41** 0.28** 0.45** 0.15 0.02 0.17 0.35** 0.25* 0.43** 0.06 0.24* 0.19 0.30** 0.30** 0.40** 0.35** 0.27** 0.33** 0.37** 0.31** 0.39** 0.14 0.33** 0.34** 0.37** 0.29** 0.33** 0.45** 0.40** 0.46**

Values given are of Pearson Correlation * Correlation is significant at the 0.01 level (2-tailed) ** Correlation is significant at the 0.05 level (2-tailed)

the assessments (e.g. a negative correlation between the burden factor of spouse related and the problem focused coping at 6 months assessment in the schizophrenia group), but these were not consistent across all the assessments.

Discussion
In the present study, patients with schizophrenia and BAD were found to impose similar levels of burden on their caregivers. Both the caregiver groups adopted problem solving and seek social support type of coping strategies more often than the avoidance strategies. A positive correlation was, however, observed between various burden factors and the use of avoidance strategies in both the caregiver groups. Patients and caregivers in the two illness groups were similar in most of the sociodemographic characteristics, except for an over representation from rural area in the BAD group, a chance nding. Majority of the patients were males, a usual pattern in

the Indian health settings. Most of our patients were gainfully employed, having recovered from the acute illness and being clinically stable. However, we dont have any information on their level of functioning in job. Caregivers of married patients with BAD experienced higher burden than those of the unmarried at all the three assessments and those of schizophrenia only at the baseline. This could be because the married patients with the additional responsibility of their spouse and children are likely to impose more burden on their caregivers. No other differences in burden and coping were observed across various sociodemographic variables in both the caregiver groups. Schizophrenia has been identied as contributing to caregiver burden for a long time [1, 4, 6, 31]. Affective disorders due to their episodic nature would be expected to cause lesser burden than schizophrenia, which is mostly identied with a chronic course. Some earlier studies had also shown such results [3, 29], refuted by the later studies, which reported substantial burden in caregivers of patients with BAD, comparable to that seen in schizophrenia [2, 20, 24].

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This nding is further conrmed by the present study, which had also the advantage of being longitudinal in nature. The nding of comparable levels of caregiver burden in BAD, as in schizophrenia, emphasizes the need to devote equivalent levels of resources towards BAD, which has sometimes not been given as much importance [17]. We did not nd a signicant change in burden over the 6 months follow up, though there was some reduction in the severity of illness. However, there was a fall in scores on the burden factor of taking responsibility. Earlier workers have reported conicting ndings on the subject. For example, Magliano et al. [13] did not nd any major changes in burden over a year in their longitudinal study on caregivers of patients with schizophrenia, though a reduction in family burden was observed among relatives who adopted less emotion focused coping strategies and received more practical support from their social network. Improvement of patients social functioning was associated with reduction in the burden. However, some other studies have reported reduction in burden in caregivers of schizophrenia patients following treatment and psychoeducational interventions in periods varying from 3 to 30 months [15, 16, 18, 28]. Somewhat similar ndings have been reported in bipolar disorders [8, 26], though there are not many longitudinal studies. Heru and Ryan [8] in one year follow up of the caregivers of the mood disorders patients who were discharged from the hospital, found signicant reduction in burden in bipolar group, but no change in the caregivers of patients with depression. In another study on bipolar disorders, psychoeducational interventions were found to reduce the subjective burden, but did not have any effect on the objective burden [26]. Maladaptive ways of functioning in the family and the expressed emotions are associated with increase in the perceived burden and affect caregiving. Family interventions and pychoeducational approaches could be helpful here. In fact, psychoeducational approaches have specically been reported to reduce the severity of illness along with associated disability and burden, and also improve communication in the family [15, 18]. We had also used psychoeducational interventions in our study, but all caregivers could not be covered. More so, the interventions were not as intensive and as structured as used in earlier works [15, 26]. The two groups of caregivers who received the psychosocial interventions and who did not receive might have had some differences on follow up, but these were not analyzed. This could be one reason for no change in burden seen on follow up, but appears unlikely since the caregivers had received just one or two sessions of the psychoeducational interventions. The reason for no change in caregiver burden over time in our study could also be that our patients were clinically stable before being included in the study.

In this study, caregivers of schizophrenia and BAD patients were found to use similar kind of coping strategies to deal with their burden. Both the caregiver groups used the problem focused and seek social support coping strategies more often than the avoidance strategies. In some of the earlier studies, caregivers of patients with schizophrenia have been reported to use emotion focused strategies more often than those caring BAD patients [2]. Another comparative study of burden from the same centre [19] has reported more frequent use of coercive coping and resorting to behaviours like smoking, drinking or taking pills by caregivers of patients of schizophrenia than those of BAD patients. However, both these studies were cross sectional in nature. Coping styles are affected by caregiver burden and distress [2]. In our study, though the caregivers were more often using the healthier coping methods of problem solving and seek social support, a positive correlation was observed between use of avoidance strategies and various burden factors. Some of the burden factors like physical and mental health, caregivers routine and patients behaviour positively correlated with the use of seek social support coping strategies in the BAD group. A positive correlation of seek social support strategies was also seen with the burden factor of physical and mental health in schizophrenia group. Scazufca and Kuipers [30] have also earlier reported a positive correlation between burden, and use of avoidance and seek social support type of coping strategies in their sample of caregivers of patients with schizophrenia. There was a dropout of nearly one third of sample over the 6 months follow up. However, this may not have affected the results as the patients and caregivers who dropped out did not differ from the completers on various sociodemographic and clinical characteristics. Dropout could be a due to a number of reasons. Caregivers and the patients may not have felt the need for follow up because the patients were clinically stable. Clinical services in India and this part of the world are often not appointment based and anybody who registers on a day in a clinical service is seen by the doctor. Since the service seekers are not in habit of keeping the appointment, this could also be a reason for high dropout. In addition, it is possible to get the medications from the private pharmacy shops without a fresh prescription (though the local law does not permit it). Thus many times, the patients take medications directly from the pharmacies, if they are not able to visit the doctor. The study had a few limitations. It did not have a random design and the assessors were not blind to the two groups. Adherence to treatment was not assessed formally except for conrming from the patients and caregivers that the patients were taking their medications. No comparisons were made between patients and caregivers, who attended the psychoeducation sessions and those who could not attend. There were

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no assessments of the level of patients functioning, which is an important variable affecting the caregiver burden. To conclude, the present study compared prospectively caregivers of clinically stable patients of two severe mental disorders (schizophrenia and BAD) on their perception of burden and coping. Both the groups of caregivers suffered nearly similar level of burden and used similar pattern of coping strategies. Further longitudinal studies are required on burden and coping in caregivers of patients with severe mental disorders to understand their complex relationship. The study also emphasizes the need of policy planners to devote more resources towards the BAD, which imposes about the similar levels of burden as schizophrenia, and has been ignored sometimes.
j Acknowledgements The authors are grateful to the Indian Council of Medical Research for financially supporting the study; Professor N.G. Desai and Dr. D.K. Gupta, Department of Psychiatry and Professor J.S. Bapna former Director, Institute of Human Behaviour and Allied Sciences, Dilshad Garden, Delhi 110095, India for their help and contributions to the work at different stages; and Dr. H.C. Joshi, Ms Ashima Srivastava and Ms Himali Bangia, the research staff of the study. The authors would also like to express their thanks to Dr. S.K. Khandelwal, Professor of Psychiatry, All India Institute of Medical Sciences, New Delhi, India for his valuable comments on the manuscript.

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