From Caregiving to Bereavement: Mental Health Trajectories of Wife and Daughter Caregivers

word count: 125 Text word count: 4,899 Running Head: From Caregiving to Bereavement From Caregiving to Bereavement 2 From Caregiving to Bereavement: Trajectories of Depressive Symptoms among Wife and Daughter Caregivers Abstract This study examined the trajectory of depressive symptoms for wife and daughterThis study examined the trajectory of depressive symptoms for wife and daughter caregivers during the transition from caregiving to bereavement, and investigated whether the trajectory varies by caregivers’ caregiving stress, social support, and background characteristics. Hierarchical linear modeling was used to analyze four-wave longitudinal data collected from 157 wife and daughter caregivers who lost elderly relatives to death. Results show that on average, caregivers experience increasing depressive symptoms as their care recipients are closer to death and decreasing symptoms after. Care recipients’ problematic behavior, caregivers’ feeling of overload, kinship, and income moderate the change in depressive symptoms during the transition. Services to support caregivers should target specific groups of caregivers, based on caregiving experience and background characteristics, at times when they are most in need. From Caregiving to Bereavement 3 From Caregiving to Bereavement: Trajectories of Depressive Symptoms among Wife and Daughter Caregivers Caregiving and bereavement are often inter-related, as most deaths of older persons in America occur after a period of chronic illness, disability, and family caregiving (Bass, Bowman, & Noelker, 1991; Schulz, Newsom, Fleissner, Decamp, & Nieboer, 1997). The literature, however, tends to treat these events separately. Studies of family caregiving have largely focused on the time when caregiving is active, whereas bereavement studies usually focus on adjustment after the death (Schulz et al., 2001). Rarely is the same sample followed from caregiving through bereavement. In this study, caregiving and bereavement are viewed as an ongoing process that exists in a chronic context (Pearlin, 1989). The study has two aims: to examine how depressive symptoms of wife and daughter caregivers change in transitioning from caregiving to bereavement; and to investigate whether caregivers’ trajectories of depressive symptoms during this transition vary by their pre-death caregiving stress and social support, and their kinship relationship with care recipients and income. Bereavement Models Death of a close relative is one of the most stressful life events (Holmes & Rahe, 1967). Studies of the general bereaved population, however, tend to concur that the mental health effect of bereavement attenuates over time; few bereaved persons experience prolonged adverse effects (Norris & Murrell, 1990). For those who have cared for the deceased, two models regarding their adjustment process have been proposed, both based on the stress and coping paradigm (Bass & Bowman, 1990; Schulz et al., 1997). The depletion model suggests that caregiving is a chronic stressor that depletes personal and social resources. Therefore in From Caregiving to Bereavement 4 facing another stressor (bereavement), caregivers are not equipped to cope and vulnerable to negative consequences. The relief model also asserts that caregiving is stressful; however, it proposes that death of care recipients provides stress relief to caregivers and allows them to reengage in other roles and activities, which ease their adjustment to bereavement. Empirical studies on caregivers’ change in mental health following their care recipients’ death have been inconclusive. Some found that caregivers do not become less depressed after bereavement; rather, their pre-death levels of depression continue well into the post-loss period, with a trajectory similar to that of continuing caregivers (Bodnar & KiecoltGlaser, 1994; Seltzer & Li, 2000). Others found that caregivers’ depressive symptoms increase in the months immediately after the death, then decline at varying rates over time (Chentsova-Dutton et al., 2002; Mullan, 1992; Schulz et al., 2003). The different trajectories of depressive symptoms found in caregivers after the death of their care recipients might in part be due to study differences in timing, interval, duration, and number of observation. Caregivers’ experience of distress is likely to vary during the time before and after care recipients die. The direction and extent of change therefore may depend on when preand post-loss assessments are conducted. The interval between assessments and the duration of observation matter because too long an interval may miss changes that are transient, whereas too short an observation period cannot detect long-term changes. Finally, using two time points to analyze change assumes linearity, which may not capture the dynamics of caregiver depression. Thus, a primary aim of this study is to examine changes in caregivers’ depressive symptoms during the bereavement transition employing a design and methodology that overcomes limitations of prior studies. From Caregiving to Bereavement 5 Diversity Within Caregivers Caregivers’ response to bereavement is likely to vary, given their variation in responding to caregiving (Pinquart & Sorensen, 2003). Based on the caregiving stress process model proposed by Pearlin and colleagues (1990), this study examines the effects of three sets of factors (caregiving stress, social support, and caregiver background characteristics) on caregivers’ trajectories of depressive symptoms during the transition from caregiving to bereavement. Caregiving Stress Caregiving stress refers to conditions, experiences, and activities arising from caregiving that are problematic (Pearlin et al., 1990). According to Pearlin et al.’s model, caregiving stress has both objective and subjective aspects. Objective caregiving stress refers to stressors that stem from care recipients’ needs and the associated care demand, such as care recipients’ problematic behavior and limitations in basic and instrumental activities of daily living (ADL/IADL; e.g., bathing, dressing, housekeeping). Subjective caregiving stress refers to caregivers’ subjective experience of hardships in the caregiving role, such as feelings of overload and burden. From the perspective of the relief model mentioned above, caregivers who experience high stress during caregiving should feel great relief upon exiting the caregiving role; hence, their mental health recovery should be faster than low-stress caregivers. On the contrary, the depletion model suggests that more intense stress during caregiving depletes more coping resources, so caregivers have more difficulties adapting to bereavement. Neither model specifies whether subjective and objective stress operate the same way. From Caregiving to Bereavement 6 Previous studies investigating the effects of caregiving stress on caregivers’ bereavement adjustment have mostly focused on subjective stress, and the results are mixed. Schulz and colleagues (2001), for example, found that spouse caregivers reporting more strain associated with caregiving are more likely to improve in health risk behaviors and have no further increase of depressive symptoms following their spouse’s death, compared to spouse caregivers with low strain and with spouse non-caregivers. Skaff et al. (1996) found that bereaved caregivers with higher levels of role captivity during caregiving have greater increase of mastery after their care recipients die. Bass and Bowman (1990), however, found that caregivers reporting more difficulties in caregiving also report more difficulties in bereavement. Bernard and Guarnaccia (2003) found that for husband (but not daughter) caregivers, greater pre-bereavement caregiver strain predicts worse bereavement adjustment. The latter two studies, however, did not control for caregivers’ pre-death distress, which may confound their findings. Few studies have examined the effect of objective caregiving stress on bereavement adjustment, except Mullan (1992) who found that ADL assistance provided by caregivers predicts increased depressive symptoms of caregivers after their recipients’ death. Social Support Social support has been conceptualized as a resource that has direct and indirect benefits to caregivers (Pearlin et al., 1990). Various dimensions of social support have been used to predict bereavement outcomes and well-being in the literature. Research consistently shows that perceived support, such as satisfaction with support, is the strongest predictor (Bass & Bowman, 1990; Krause, 2001). A prior study found that more satisfaction with the support received during caregiving predicts less difficulty experienced in bereavement by From Caregiving to Bereavement 7 caregivers, and that satisfaction with caregiving support is a better predictor than satisfaction with bereavement support for caregivers’ bereavement adaptation (Bass et al., 1991). Caregivers’ Background Characteristics It’s been suggested that the influence of caregivers’ key characteristics be threaded through the entire stress process (Pearlin et al., 1990). In this study, I examine two caregiver characteristics (kinship and income). Kinship matters because different role relationships involve different expectations, obligations, and identities. Wife and daughter caregivers, for instance, vary greatly in their obligation to care and the meaning of loss when their care recipients die. Wives should be more psychologically reactive to caregiving and bereavement than daughters because of the relative salience of the role of wife to women (Seltzer & Li, 2000). Caregivers’ income is an indicator of their socioeconomic status (SES). Prior research has shown that individuals with low SES are more susceptible to negative effects of caregiving (Roth, Haly, Owen, Clay, & Goode, 2001) and bereavement (Arbuckle & de Vries, 1995; Norris & Murrell, 1990), and caregivers with limited income are likely to decrea