Author:
Anahita khodabakhshi koolaee (PhD)
University of Social Welfare and Rehabilitation Sciences,
Evin, Kudakyar Ave.,
Tehran, 19834, Iran.
E-mail: anna_khodabakhshi@yahoo.com

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INTRODUCTION
Family caregivers of persons with schizophrenia and other psychotic disorders experience high level of burden. Since de-institutionalisation of the mentally ill, their relatives have been faced with numerous and long lasting caring demands due to the complex needs and problems especially of the chronic ill (Moller-Lemkuhler, 2003).

In Iran the number of schizophrenia patients returning to their families after hospitalization increased in the 1990s. It is estimated that 65%-75% of patients are living with their families. Iranian families prefer to keep patients in the family (Khodabakhshi koolaee, 2008). Taking care of a patient with schizophrenia and other mental illness has been shown to place a significant burden on the caring families (Khodabakhshi koolaee & Etemadi, 2009).

The research indicates that the caregivers experience reduction of well-being, restrictions in leisure time, daily routine and social contacts, and emotional problems (Kuipers, 1993; Provencher, 1996). Furthermore, the families or caregivers must cope with the stress of the patient's disruptive symptoms, changes in household routines, strained social relations within the family, loss of social support, diminishing opportunities for leisure time and deteriorating finances (Stengard, 2003).

If the caregivers are in their old age, the problems and stress due to caring for the patients will be in high levels. Moreover, the elderly caregivers always ask themselves, who will care for their patients when they are not there. Although, some research was done on the effects of care giving of psychotic patients, most studies did not include older caregivers and the mental health problems they encountered.

To our knowledge this is the first study in which such a comprehensive assessment of care giving outcome of the elderly caregivers has been performed in Iran. Therefore, the present study was undertaken to examine this hypothesis:

Is the mental health of the elderly caregivers affected by caring for schizophrenia patients?


METHODS
Subjects:
Patients who lived with a parent were informed and then 50 caregivers who were eligible to participate were selected for study. 45 of them were mothers and 5 of them were fathers. The mean age was 65. Other criteria of selection of patients and parents are listed as follows:

a) They were living with and caring for one child with a primary diagnosis of schizophrenia, according to criteria of the DSM-IV (American Psychiatric Association, 2000).

b) They were aged 60 years and above.

c) They were able to read and write Persian.

d) They had the same social-economic status (SES).

e) They wrote the consent letter to participate in research.

f) Parents with a schizophrenic child and no other mental illness, and the duration of the schizophrenia was 3 years or less at the time of recruitment were included.

Parents were excluded if:

a) They had a diagnosis of psychotic disorders like delusional disorders or schizophrenia and so on;

b) They cared for more than family member with chronic physical or mental illness;

c) They had been the primary carer for less than 3 months.

Measure:
The participants completed General Health Questionnaire (GHQ) Persian version. The General Health Questionnaire-28 is frequently used as an indicator of psychological Well-being and this latter construct resembles the psychological dimension of quality of life (Goldberg and Hillier 1979, Sanderman and Stewart 1990, EURIDISS 1990, Krol et al. 1994). The GHQ as a self-report instrument was designed for detection and assessment of individuals with an increased likelihood of current psychiatric disorder (Goldberg and Hillier 1979, McDowell and Newell 1987, Goldberg and Williams 1988). The original questionnaire consists of 60 items from which shorter versions of 30, 28, 20 and 12 items were developed. The GHQ-28 scale was derived by factor analysis of the original 60-item version and prepared mainly for research purposes. However, as already mentioned, the scale is often used as a measure of psychological well-being also (Goldberg and Williams 1988, EURIDISS 1990, Krol et al. 1994). The GHQ-28 incorporates four subscales: somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression. The existence of four subscales permits analyses within the subscales and this is an additional advantage of the GHQ-28 scale over the other versions (Goldberg and Hillier 1979, Bowling 1992). For each item four answer possibilities are available (1-not at all, 2-no more than usual, 3-rather more than usual, 4-much more than usual). In the study the Likert scoring procedure (1, 2, 3, and 4) is applied and the total scale score ranges from 28 to 112. The higher the score is the poorer the psychological well-being of the patient (Nagyova, 2000). In 1996 this questionnaire translated to Persian by Hooman and Reliability analysis showed satisfactory result (Cronbach's alpha coefficient = 0.84). In addition, in other study reliability measured again and the results indicated satisfactory result (Cronbach's alpha coefficient = 0.87) khodabakhshi koolaee (2006). In this study, use the Persian version.

In addition, the participants completed a socio-demographic data sheet. Also, the psychiatric records of patients were studied.

Statistical analysis:
Descriptive statistics were used to describe the sample characteristics and the results from each scale. Analyses were preformed with SPSS 11.5 for windows.

RESULTS
The socio-demographic characteristics of caregivers and patients were summarized (Table 1).

Table 1: Socio- demographic Characteristic of mothers and patients in study all of participants

Data were calculated of the GHQ & all GHQ subscales questionnaire Ttable2). 20 out of all participants reported social dysfunction. In addition, 12 out of all subjects said they had sleep disturbance and 12 out of all participant reported the somatic symptoms and they are met physician and using drugs. Furthermore, 10 out of them reported the high depression and met psychiatrist every month for treatment.

Table 2: The frequency and percent of GHQ subscales among participants

38 subjects out of 50 participants had acquired low mental health (76% of the parents report disturbance in their mental health, (Table 3).

Table 3: The frequency and percent of total score of GHQ among participants

DISCUSSION
The results indicted that 76% of the older caregivers reported low mental health. Care giving of psychiatric patients can take a heavy toll on caregivers. Indeed, when the caregivers were in old age the stress of caring patients were doubled. Older caregivers said that they must deal with psychotic symptoms of their patients every day and tried to solve them.

On the other hand, Iranian parents are regarded to emotionally over involvement attitude toward their patients. Parents who had high expressed emotion (EE) with emotional over involvement (EOI) were very self - blamer and more controlling than other parents (khodabakhshi Koolaee, 2009). They always tried to control all of things in their life, so they more encountered stress.
Burden was significantly associated with several psychosocial resources and dispositions of the relatives (Moller-Lemkuhler, 2005).

The present findings shed additional light on the relatives of the elderly caregiver's burden. First, parents report that overwhelming anxiety and lack of knowledge about how to go about planning were the biggest personal barriers they faced. Second, of importance also were financial limitations and lack of understanding about the best ways for accessing services.

In general, in response to the stress of caring, a variety of comprehensive family interventions for patients and their families has been developed.

Falloon(2003) discussed the aims of the family interventions are enhance the care giving capacity of family members and other people involved in the day to day care for people with mental disorders have a clinically significant impact on the course of major mental disorders. Also, Falloon (2003) reported that the best results appear to be associated with comprehensive a methods that integrate carers into the therapeutic team through education and training in stress management strategies, with continued professional support and supervision over a period of at least two years. Benefits from family approaches are also evident for the carers themselves, with reduced stress associated with their care giving roles.

Moreover, Hatfield (2003) provided a four hour workshop was designed to take caregivers step by step theory and planning process. 1) An overview of the planning process (caregivers are encouraged to identify kinds of resistance that may be preventing them from tackling the issue of future planning. 2) learning about community recourses (representatives from the fields of mental health, aging, and social services. 3) developing trusts and wills(Hatfield, 2003).

As falloon (2003) said, almost all patients have somebody who cares for them, or at least somebody who cares about them. With improved understanding and straightforward training in problem solving approaches caregivers can provide a substantial additional resource to the therapeutic team, a resource that promises to contribute to long-term clinical and social recovery from major disorders.

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