1. Background
Today, chronic mental disorders are recognized as one of the most significant global health issues (1). These disorders have far-reaching implications for health, quality of life, and the economic and social aspects of society, imposing substantial costs on healthcare systems worldwide (2, 3). Mental disorders also contribute to premature mortality (4), with an estimated 14.34% of global deaths attributed to mental disorders, accounting for approximately 8 million deaths annually. Consequently, mental disorders can be regarded as a major contributor to worldwide mortality (5). According to the Global Burden of Disease Report in 2017, approximately 971 million individuals worldwide are affected by mental illnesses to varying degrees, constituting 13% of the global population (6). Numerous studies conducted in Iran also highlight the escalating prevalence of mental disorders. For example, research by Taheri Mirghaed et al. estimated the prevalence of psychiatric disorders to be 30.03% based on screening tools and 25.42% based on clinical interviews (7). These increasing rates of mental disorders affect not only the individuals with the disorders but also their family members, exposing them to secondary stressors (8).
Family caregivers encompass relatives, friends, and even the friends of the patient who provide unpaid care for individuals with physical or mental disabilities at home, assisting them in their daily activities and aiding in their rehabilitation efforts (9). Often referred to as "latent patients," these caregivers play a crucial role in reducing the frequency of patient readmissions (10). For instance, a study by Rodakowski et al. demonstrated that involving caregivers in discharge planning for the elderly led to a 25% and 24% reduction in readmissions within 90 and 180 days, respectively (11). However, due to the lack of adequate training for caregiving, family caregivers frequently experience significant adverse psychological effects (12) and grapple with various challenges in the psychological, social, and economic domains (13). Research indicates that family caregivers encounter numerous difficulties, including depression, anxiety, high levels of stress, reduced quality of life, increased burden, fatigue, sleep disturbances, memory and concentration issues, financial pressures, and interpersonal conflicts (14-16). Therefore, it is essential to comprehensively address the challenges faced by family caregivers to support and enhance their mental well-being (17). Numerous studies have identified various factors and interventions, including coping strategies, that can be effective in mitigating and managing caregiver stress and burden (18, 19).
Coping strategies refer to the methods, strategies, and approaches individuals employ when faced with stressful or unpleasant situations, with the aim of either effectively or ineffectively addressing those situations. These strategies encompass problem-oriented, emotion-oriented, and avoidance strategies. Problem-oriented coping involves focusing on problem-solving, while emotion-oriented coping entails addressing and reducing unpleasant emotions. Avoidant coping, on the other hand, seeks to evade the stressful situation altogether (20, 21). Research has consistently demonstrated that the effective use of coping strategies can reduce or eliminate stress (22), while ineffective coping strategies can exacerbate caregiver burden (23). Marimbe et al. have shown that family caregivers of individuals with mental illnesses often struggle to employ appropriate coping strategies when confronted with adverse circumstances (24). Furthermore, research conducted by Rahmani et al. in Iran revealed that family caregivers of patients with mental disorders tend to rely on maladaptive coping strategies, placing them at risk for mental health issues and increased stress levels. Hence, the importance of coping strategies and stress management cannot be overstated (25).
Research findings indicate that mentally healthy individuals are more likely to employ problem-oriented coping strategies and are less inclined to rely on emotion-oriented coping strategies (26, 27). Rahnama et al.'s study results also demonstrated that caregivers who utilized problem-oriented coping reported lower levels of anxiety (28). Given the significant role of effective coping strategies in enhancing mental health, reducing stress and anxiety, and addressing the various challenges faced by family caregivers (10), it is crucial to explore this psychological component and its related factors.
Numerous studies have highlighted the substantial and additional burdens that chronic mental disorders place on the healthcare systems of countries (29). Given the dearth of research in the field of family caregivers of patients with chronic mental disorders and the high prevalence of such disorders, conducting further studies across various domains is crucial. These studies can provide valuable insights and support to enhance the mental well-being of this population.
2. Objectives
The primary objective of this study was to investigate coping strategies among family caregivers of patients with chronic mental disorders. It is believed that assessing coping strategies among family caregivers of individuals with chronic mental disorders can inform the development and design of preventive programs aimed at preserving and improving the mental health of this population in Iran.
3. Methods
3.1. Research Method, Statistical Population, and Sample
This descriptive-analytical study was conducted among 188 family caregivers of patients with chronic mental disorders visiting Farabi and Khorshid psychiatric hospitals affiliated with Isfahan University of Medical Sciences. The data were collected over a 127-day period, and participants were selected using a convenient sampling method. Also, the sample size was determined (n = 157) based on the sample calculation formula as below for correlation studies, taking into account the correlation coefficient of 0.28 (r = 0.28), the power of 95% (β - 1), and the 95% confidence interval for type 1 error (= 0.05α). Finally, the sample size was determined as 188, assuming a 20% sample attrition rate (30).
Three participants who returned incomplete questionnaires were excluded from the study, leaving a final sample of 185 individuals for analysis. The inclusion criteria were as follows: (1) Willingness to cooperate and participate in the study; (2) literacy; (3) a minimum of 6 months of caregiving experience for a family member with a chronic mental disorder; (4) no history of known chronic psychosis; (5) media literacy if data were collected online, including access to facilities such as smartphones and the internet; (6) no history of severe stress, such as the death of a loved one or divorce, and no history of caregiving for more than 1 patient in the last 6 months. Participants returning incomplete questionnaires were excluded based on the exclusion criteria.
3.2. Data Collection Method
Data collection took place in person at a predetermined location. All participants received a briefing on the research's design and objectives, as well as instructions on how to complete the questionnaires. They were also assured of the confidentiality of their information and provided informed consent. Subsequently, participants were given the questionnaires to complete independently. This process continued until all designated samples had completed the questionnaires. On average, participants required approximately 20 minutes to complete the questionnaires. Given that some family caregivers might have had difficulty understanding certain questions, the researcher read each question aloud and marked the chosen response selected by the family caregiver. It is worth noting that the data collection period spanned from February 7, 2021, to June 14, 2021, lasting for 127 days.
3.3. Ethical Considerations
This study adhered to the principles of the Declaration of Helsinki. Family caregivers were provided with a clear explanation of the study's objectives, and their informed written consent was obtained, ensuring the confidentiality of their data. The research protocol received approval from the Ethics Committee of Isfahan University of Medical Sciences under the ethics code IR.MUI.RESEARCH.REC.1399.701.
3.4. Measurement Tools
The data collection tools included a demographic characteristics form and the Endler and Parker Coping Inventory for Stressful Situations–Short Form (CISS-SF).
3.4.1. Demographic Characteristics Form
This form included the following characteristics: Age, sex of the caregiver, sex of the patient, marital status, number of family members, the patient's relative(s), educational level, diagnosis of the patient's disease, patient care and occupation, and whether they lived in a rural or urban setting. It also included information about the patient's history of hospitalizations due to illness.
3.4.2. Coping Inventory for Stressful Situations–Short Form
The questionnaire comprises 21 questions, with each question containing 5 response options (never, rarely, sometimes, often, very much) scored from 1 to 5, respectively. The coping strategy style is determined based on the average score obtained by a person from specific questions. Questions 1, 4, 7, 9, 15, 18, and 21 measure the avoidance coping style; questions 2, 6, 8, 11, 13, 16, and 19 measure the problem-based coping style; and questions 3, 5, 10, 12, 14, 17, and 20 measure the emotion-based coping style. A higher score in any of the 3 styles indicates the predominant coping strategy of an individual. The maximum score for each style is 35, and the minimum is 7. The questionnaire's validity and reliability have been previously confirmed in various studies (31, 32).
3.4.3. Data Analysis
Data analysis was conducted using SPSS v. 20 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including frequency, percentage, mean, and standard deviation, were employed for the descriptive analysis. Inferential statistics, such as independent t-test, one-way analysis of variance (ANOVA), Pearson correlation coefficient, and Spearman correlation coefficient, were utilized for inferential analysis.
4. Results
4.1. Demographic Characteristics
The findings revealed that the mean age of family caregivers was 42.51 years with a standard deviation of 11.899, and the mean duration of the patient's diagnosis was 5.829 years with a standard deviation of 5.23. The majority of the participants were female (64.9%), married (68.65%), and homemakers (33.5%), with a secondary level of education (51.4%). Additionally, 33.5% of caregivers were homemakers, and 45.9% of their patients were diagnosed with bipolar disorder. Approximately 54.3% of patients had a history of hospitalizations fewer than 5 times. The most common relationship between caregivers and patients was that of mother and child (38.92%), and the majority of caregivers lived in urban areas (Table 1).
| Variables (Qualitative) | No. (%) or Mean ± SD |
|---|---|
| Caregiver's sex | |
| Male | 65 (35.1) |
| Female | 120 (64.9) |
| Marital status | |
| Single | 58 (31.35) |
| Married | 127 (68.65) |
| Relationship with the individual | |
| Father | 22 (11.9) |
| Mother | 72 (38.92) |
| Spouse | 41 (22.16) |
| Sister | 13 (7.03) |
| Brother | 8 (4.32) |
| Cousins | 23 (12.43) |
| Others | 6 (3.24) |
| Patient's sex | |
| Male | 109 (58.92) |
| Female | 76 (41.08) |
| Educational level | |
| Secondary study | 95 (51.4) |
| High school diploma or associate's degree | 59 (31.9) |
| Bachelor's degree | 24 (13) |
| Master's degree | 6 (3.2) |
| PhD | 1 (0.5) |
| Occupational status | |
| Self-employed | 49 (26.5) |
| Registered civil servant | 15 (8.1) |
| Unregistered clerk | 19 (10.3) |
| Unemployed | 23 (12.4) |
| Homemaker | 62 (33.5) |
| Retired | 17 (9.2) |
| Disease | |
| Depression | 34 (18.4) |
| Bipolar | 85 (45.9) |
| Schizophrenia | 47 (25.4) |
| Schizoaffective | 4 (2.2) |
| Others | 15 (8.1) |
| Residential status | |
| Urban | 160 (86.5) |
| Rural | 25 (13.5) |
| Caregiver's age, y | |
| Under 21 | 18 ± 1 |
| 21 - 30 | 26 ± 3 |
| 31 - 40 | 36 ± 3 |
| 41 - 50 | 46 ± 3 |
| 51 - 60 | 55 ± 2 |
| Higher than 60 | 63 ± 2 |
| Number of family members | |
| Under 4 | 3 ± 1 |
| 4 - 6 | 5 ± 1 |
| Higher than 6 | 8 ± 1 |
| Caregiving period, mo | |
| Under 6 | 2.088 ± 1.443 |
| 6 - 10 | 6.926 ± 1.211 |
| 11 - 15 | 12.28 ± 1.370 |
| 16 - 20 | 16.571 ± 1.134 |
| Higher than 20 | 27 ± 7.211 |
| Frequency of hospitalizations due to the mental disorder, times | |
| Under 5 | 2 ± 1 |
| 5 - 10 | 6 ± 1 |
| Higher than 10 | 12 ± 1 |
Frequency Distribution of Participants' Demographic Variables
4.2. Coping Strategies
According to the findings, the mean scores for problem-oriented, emotion-oriented, and avoidance coping strategies were estimated to be 19.664 ± 7.426, 21.956 ± 6.207, and 18.297 ± 5.741, respectively (Table 2). Additionally, the findings indicated that 55.1% of family caregivers primarily used emotion-oriented coping strategies, 30.3% adopted problem-solving coping strategies, and 14.6% relied on avoidance coping strategies. Consequently, coping strategies were somewhat ineffective for 69.7% of the participants (Table 2).
| Coping Strategies | No. | Mean ± SD | Min | Max | No. (%) |
|---|---|---|---|---|---|
| Task-oriented coping strategy | 185 | 19.664 ± 7.426 | 3 | 35 | 56 (30.3) |
| Emotion-oriented coping strategy | 185 | 21.956 ± 6.207 | 6 | 34 | 102 (55.1) |
| Avoidance-oriented coping strategy | 185 | 18.297 ± 5.741 | 6 | 33 | 27 (14.6) |
Mean Scores and Frequency Distribution of the Underlying Coping Strategies
4.3. Relationship Between Coping Strategies and Demographic Characteristics
It is worth noting that there was no significant relationship between any of the demographic characteristics and coping strategies (P > 0.05) (Table 3).
| Variables | Type of Coping Strategies | |||||
|---|---|---|---|---|---|---|
| Avoidance-Oriented Coping Strategy | Emotion-Oriented Coping Strategy | Task-Oriented Coping Strategy | ||||
| P-Value | Correlation Coefficients | P-Value | Correlation Coefficients | P-Value | Correlation Coefficients | |
| Pearson's Correlation Coefficients | ||||||
| Caregiver's age | 0.962 | -0.004 | 0.556 | 0.044 | 0.623 | 0.036 |
| Number of family members | 0.507 | 0.049 | 0.454 | 0.055 | 0.094 | 0.123 |
| Caregiving period | 0.583 | 0.041 | 0.194 | 0.096 | 0.554 | -0.044 |
| Frequency of hospitalizations due to mental disorder | 0.831 | -0.016 | 0.720 | 0.027 | 0.567 | 0.042 |
| Spearman's Correlation Coefficients | ||||||
| Educational level | 0.408 | 0.061 | 0.649 | 0.034 | 0.053 | 0.142 |
| independent t-test | p | t | p | t | p | t |
| Caregiver's sex | 0.682 | -0.410 | 0.707 | -0.376 | 0.921 | 0.099 |
| Marital status | 0.360 | -0.917 | 0.247 | -1.163 | 0.664 | 0.435 |
| Patient's sex | 0.074 | 1.796 | 0.522 | 0.642 | 0.567 | 0.573 |
| Residential status | 0.697 | 0.390 | 0.255 | 1.141 | 0.673 | 0.422 |
| One-way Analysis of Variance (ANOVA) | P | F | P | F | P | F |
| Disease | 0.520 | 0.810 | 0.572 | 0.731 | 0.532 | 0.791 |
| Occupational | 0.819 | 0.441 | 0.354 | 1.116 | 0.756 | 0.526 |
| Relationship with the individual | 0.456 | 0.957 | 0.473 | 0.933 | 0.814 | 0.492 |
The Coping Inventory for Stressful Situations–Short Form (CISS-SF) Scores of Caregivers and Demographic Characteristics
5. Discussion
The primary objective of this study was to identify the coping strategies employed by family caregivers of patients with chronic mental disorders. The findings revealed that 69.7% of participants' family caregivers utilized ineffective coping strategies, with 55.1% employing emotion-based coping strategies and 14.6% resorting to avoidance coping strategies. Conversely, 30.3% of caregivers employed effective coping strategies, namely problem-oriented strategies. It is worth noting that, unlike defense mechanisms, coping strategies typically involve a conscious and direct approach to addressing problems (33). This finding aligns with a study by Rahnama et al. titled "The Relationship between Anxiety and Coping Strategies in Family Caregivers of Patients with Trauma" (28). Additionally, Abbasi et al. found that the majority of family caregivers of cancer patients utilized emotion-based coping strategies (34).
The results of the present study also concur with studies conducted by Iavarone et al. (35), Sharif et al. (36), and Rahmani et al. (25). These studies collectively suggest that family caregivers of individuals with mental illnesses often struggle to apply appropriate coping strategies when confronted with challenges and stressful situations. However, Pompeo et al.'s research indicated that most family members of patients with mental disorders primarily employ social support and problem-based coping strategies, which contrasts with our findings (37).
Furthermore, Menati et al.'s study involving 103 caregivers of hemodialysis patients revealed that avoidance coping strategies were the most commonly employed coping strategies (19). The results of our study, however, were inconsistent with Sa'adati and Lashani's study (30) on students at the University of Social Welfare and Rehabilitation Sciences in Iran and Marimbe et al.'s study (24) on family caregivers of patients with mental disorders in Zimbabwe. It is important to note that these discrepancies may arise from cultural differences, variations in research tools, and differences in sample characteristics used in assessing coping strategies.
Additionally, according to the findings of the present study, none of the coping strategy styles exhibited a significant relationship with demographic information. This finding was consistent with the results of Abbasi et al. and Pompeo et al.'s studies (34, 37). However, Sa'adati and Lashani's research on students at the University of Social Welfare and Rehabilitation Sciences demonstrated, unlike our study, a significant relationship between emotion-based coping strategies and sex (30). Furthermore, Rahmani et al. studied family caregivers of patients with schizophrenia and found that there was a relationship between coping strategies and certain demographic characteristics, including age, educational level, sex, occupational status, job loss due to caregiving responsibilities, perceived income adequacy, illness, and caregiving duration (25). This apparent discrepancy may be attributed to differences in research tools, samples, and research settings.
5.1. Limitations
The moods and sociocultural status of the participants when completing the questionnaires were considered limitations of this research.
5.2. Conclusions
In conclusion, the findings of this study suggest that a majority of family caregivers of patients with chronic mental disorders struggle to employ effective coping strategies. Therefore, the sensitive and challenging situation of this group necessitates comprehensive screening programs to better understand their difficulties. It is essential to maintain social capital, vitality, and the well-being of these individuals and society through appropriate preventive measures. These results can be instrumental in shaping future plans to enhance the mental health of patients' family caregivers.
