Burden among Caregivers of Person with Schizophrenia and Schizoaffective Disorder: A Comparative Study

This is a cross-sectional comparative study with the aim to compare two patient groups of schizophrenia and schizoaffective disorder and their respective caregivers with the objectives to quantify and compare the burden in caregivers of person with schizophrenia and schizoaffective disorder and to study the relationship between them. In this study, 40 patients schizophrenia, 40 patients of schizoaffective disorder, along with their 80 respective caregivers were taken on the basis of inclusion and exclusion criteria. Subjects were assessed using Socio-demographic and clinical sheet &BAS. Appropriate statistics such as mean, standard deviation, chi-square test, unpaired t test, Pearson’s correlation were applied to analyze the data. The results of the study revealed considerable burden of care in families of the patients and a significantly greater burden of care in caregivers of patients with schizoaffective especially in the following domains: spouse related, caregivers’ routine, physical and mental health, taking responsibility, patient’s behaviour and caregiver’s strategy. Some of the demographic variables like age and education etc. were also found to have significant correlation with burden of care.

the need for long-term psychosocial and economic support, as well as life-time lost productivity. A noteworthy finding by Weidmann et al was that despite the downfall of traditional family structure from joint families to nuclear families more than 60% of persons with long term schizophrenia live with at least one significant other i.e. primary caregiver who is responsible for fulfilling most of the needs of patient and care for significant period of time. Mental health and illness are not polar opposite, but instead can be viewed as points on a continuum, which changes from day to day. We live in a society that bombards us with stressful situation continuously. It is natural for an individual to ebb and flow emotionally daily in response to the stress they are experiencing. Mentally healthy person can deal with their strees.1 Psycho educational family programmes, in combination with medication, management have been shown to make a substantial contribution to preventing relapse among psychotic patients, particularly among those with chronic schizophrenia (Mathew Samuel & Murali Thyloth) The World Health Organization (WHO) states caregiver burden as the "the emotional, physical, financial demands and responsibilities of an individual's illness that are placed on the family members, friends or other individuals involved with the individual outside the health care system. A study was conducted by WHO in 2003 concluded that there are about 40 million mentally ill persons in India. The presence of a mentally ill patient in a family cause stressful experience to the care givers especially in physical, emotional, social and financial areas. More the patient behaviour and functional disability put the primary care givers in a great risk as the care giving to a mentally ill patient is a very complex process as most of the mentally illness occur with a change in the behavioural pattern of the patient .These factors may act as a burden to the care givers and can affect even the quality of life of the primary care giver too; as a health professional the mental health nurse has a main responsibility in identifying these levels of burden, coping and quality of life among the care givers specially the primary care givers of the mentally ill patients. Globally 450 million people suffer from mental disorder. WHO 2002 showed that out of 450 million people, 154 million people suffer from depression and 25 million people from schizophrenia. Schizophrenia affects about seven per thousands of the adult population mostly in the age group of 15-35 years. Though the incidence is low (3-10,000), the prevalence is high due to chronicity.3In India 9.1% of the population suffer from depressive disorders. The estimation of schizophrenia incidence was 0.38/ 1000 in urban and 0.44/1000 in rural part of Chandigarh.
The overall incidence of schizophrenia was 0.35/1000. The prevalence is 2.5/1000(urban and rural) -Ganguli 2007. .3The initial Global Burden OF Disease study found that depression was the fourth leading cause of disease burden, accounting for 3.7% of total disability adjusted life years ( DALYS) in the world in 1990.Mental disorders cause clinically significant distress or impairment in social, occupational, and/or other important areas of functioning. This impairment is chronic and consequences of psychopathology have long lasting constraints on the level of functioning, preventing patients from recovering to their pre-morbid state resulting in chronic invalidity. So impaired functioning continues even after discharge of patient from hospital to home which leads to stress in the caregivers.

EPIDEMIOLOGY OF SCHIZOPHRENIA
According to DSM-TR, the annual incidence of schizophrenia ranges from 0.5 to 5.0 per 10,000 with some graphical region. Schizophrenia is a relatively common illness affecting approximately 0.7% of the world's population prevalence estimates from 188 studies from 46 countries life time prevalence was found to be 4.0 per 1000.Among epidemiological studies conducted in India, largest has been the longitudinal study of functional psychosis in an urban community (SOFPUC) in Chennai carried out by SCARF (schizophrenia research foundation) and department of psychiatry, Madras Medical College. First episode schizophrenia patients from a predominantly urban background were followed up and age corrected prevalence rate of Schizophrenia was estimated to be 3.87/1000. The incidence rate in same study was 0.35/1000.

EPIDEMIOLOGY OF SCHIZOAFFECTIVE DISORDER
Schizoaffective disorder is a psychiatric disorder that affects about 0.5 to 0.8 percent of the population. It is characterized by disordered thought processes and abnormal emotional responses. Common symptoms include delusions, hallucinations, disorganized speech, and bizarre behaviours, as well as mood problems. Schizoaffective disorder appears to be about onethird as common as schizophrenia. Lifetime prevalence of schizoaffective disorder is uncertain, but probably less than 1 percent, in the range of 0.5 to 0.8 percent. The incidence of the disorder is higher in females than in males, mainly due to an increased incidence of the depressive type among females. The typical age at onset of schizoaffective disorder is early adulthood, although onset can occur anywhere from adolescence to late in life.

OPERATIONAL DEFINITIONS: 1. Primary Care givers:
A person who involved in direct care of a mentally ill patient and spent most of their time for caring the patient. This is usually the family member. Depending on culture there may be other members of the family engaged in care. Such as (Father, Mother or Husband, wife or Brother, Sister)-who are providing care for the mentally ill patients. Goldman et al. (1981) defined the chronically mentally ill as " persons who suffer certain mental or emotional disorder(organic Brain syndrome, schizophrenia, Recurrent depressive and Manic depressive disorder, paranoid and other psychosis) plus other disorders that may become chronic that erode or prevent the development of their functional capacities in relation to three or more primary aspect of daily life-personal, hygiene and self-care, self-care 1. To explore the impact of burden in caregivers of person with chronic mental illness (Schizophrenia, schizoaffective). 2. To explore the impact of burden and their association with demographic factors like age, gender etc. 3. To quantify and compare the burden in caregivers of person with schizophrenia and schizoaffective disorder.

RESEARCH METHODOLOGY;
Study Setting: The study was conducted in selected Psychiatric Hospital at Lucknow (Uttar Pradesh).

Research design:
This was a hospital-based, cross sectional and comparative study.

Population:
The population of the present study will include primary care givers of patients who are diagnosed as schizophrenia, schizoaffective disorder, on the basis of ICD-10 in a selected psychiatric hospital at Lucknow.

Sample Size:
Total subjects in caregiver group 80 (40 caregivers of person with schizophrenia, and 40 caregiver's person with schizoaffective disorder respectively were taken up for study).

Sampling Plan:
Purposive sampling technique was used to select the samples for the study.

Inclusion Criteria for chronic Mentally Ill Patients
 Age group ranging from 18-60 years  Patients diagnosed as schizophrenia, schizoaffective disorder according to ICD-10  Duration of illness at least 2 years recruited to the study

Exclusion Criteria for Chronic Mentally Ill Patients
 Neurological disorders such as seizures, movement disorders, cerebral palsy  Recent or current medical illness  Co morbidity with any other psychiatric disorder.  Use of any pharmacological intervention other than psychotropic drugs.  Life time history of head injury associated with loss of consciousness, seizures, neurological deficits, or surgical intervention.

Inclusion Criteria for Caregivers
 Primary caregivers (Parents/Spouse/Sibling/Children)who are staying with the patient since the onset of illness are included.  Age group above 21 years  Living with the patient for at least last 1 year  Those who gave informed consent to participate in the study

Exclusion Criteria for Caregivers
 Caregivers with psychiatric conditions, organic syndromes, mental retardation, substance dependence or chronic physical illness.  Those who did not give consent

Tools Used
The following tools were used for the present study: A. SOCIODEMOGRAPHIC AND CLINICAL SHEET A semi-structured proforma will design to collect demographic information like age, sex, duration of marriage, etc. about the patients and their caregivers along with the clinical information like the age of onset, duration of illness, number of hospitalizations, etc. regarding the patient.

B. BURDEN ASSESSMENT SCHEDULE (BAS) OF SCARF (SCHIZOPHRENIA RESEARCH FOUNDATION)
It was developed by Thara et al based on 'stepwise ethnographic exploration' described by Sell and Nagpal in 1992.It is a semi-quantitative instrument with 40 items measuring 9 different areas of subjective and objective caregiver burden on caregiver of chronic psychotic person. 4 items are specifically pertaining to spouse. Each item is rated on a 3 point scale with 1 not at all, 2 to some extent and 3 very much. Total scores range from 40-120.Internal consistency of scale is 0.8 as measured by alpha coefficient. Factor analysis has identified nine factors based on the items:a) Spouse related, b) Physical & mental health, c) External support d) Caregiver's routine, e) Taking responsibility, f) Other relationship, g) Patient behaviour, h) Caregiver's strategy It is a comprehensive scale and gives special emphasis to spouse caregivers (has separate 4 questions for them), its reliability and validity is high and has been earlier used extensively in Indian population.

Procedure
The study was approved by the hospitals ethics committee, and all subjects gave written informed consent to participate. Person with Schizophrenia, person with schizoaffective disorder patients and their caregivers were selected by purposive sampling on the basis of inclusion and exclusion criteria from out patients of the hospitals. Detailed data was collected on the sociodemographic and clinical data sheet designed for the purpose. Subjects were assessed Burden Assessment Schedule (BAS) by Thara et al. The study sample consisted of caregivers of 40 people with schizophrenic and 40 people with schizoaffective disorder. Table 1 shows the comparison of socio-demographic variables among caregiver groups. There were no significant differences with respect to Gender (X 2 =0.052), marital status (X 2 =0.457), Education (X 2 =0.202) as well as Occupational status (X 2 =0.464) among the two groups. Most caregivers had studied below high school .48% of caregivers of Person with schizoaffective were employed compared to 41.3% of caregivers of person with schizophrenia.  Table 2: shows comparison of caregiver burden in the caregivers groups as reflected in Burden assessment schedule scores. Student t test was applied to compare the mean scores in the two groups. There was a significantly higher total burden with mean value of 82.82 (SD=8.77) in caregivers of person with Schizoaffective disorder compared to schizophrenia with mean value of 76.7 (SD=12.34). Similarly t test was applied to compare means of nine factors of burden assessment schedule. Significantly higher burden was noted in care givers of schizophrenia on 'caregivers' routine" (t=2.037)," physical and mental health" (t=3), "taking responsibility" (t=2.865), "patient behaviour" (t=2.835) and "caregiver strategy" (t=2.554). Spouse related burden could be assessed only where caregivers were spouses of patients. There were 16 spouses of person with schizophrenia and 16 spouses of person with schizoaffective disorder among the caregiver groups. Higher spouse related burden subscale (t=2.917) score was noted in schizoaffective disorder (12.14) compared to schizophrenia (mean=9.75). This was consistent with findings by Thara et al. Both schizophrenia and schizoaffective disorder are major psychiatric disorders which invariably produce burden on caregivers. The relative magnitude of the burden was compared in the present study which is higher in the caregivers of schizoaffective. The quantum of burden present in the caregivers, points out to the need for addressing the burden and related issues of the family members as well.

CONCLUSIONS
The primary aim of the study was to estimate and compare the burden of care in caregivers of the patients with schizophrenia and schizoaffective disorder. The results of the study revealed considerable burden of care in families of the patients and a significantly greater burden of care in caregivers of person with schizoaffective. Additional studies would be required to further delineate the factors associated with both burden of care and expressed emotion in the caregivers.