Psychological Distress Among Latino Family Caregivers of Adults With Schizophrenia: The Roles of Burden and Stigma

Research on Latino families who have a relative with mental illness (that is, the patient) has largely focused on how the family relates to the patient and how family attitudes and interactions may impact the patient (1–5). Data suggest that Latino family caregivers are more likely to live with the patient, be more accepting and more hopeful for a cure (6–9), and exhibit fewer critical comments toward the patient, compared with European-American families (1–3). These key cross-ethnic differences in caregiver involvement and affect may also reflect differences in the way that caregiving is linked with the course of schizophrenia. For example, low levels of caregiver warmth were a significant predictor of relapse among Latino patients but not among European-American patients (5). Researchers continue to investigate how family caregiving among Latinos may affect patients’ outcomes; however, it is equally important to attend to the well-being of family caregivers. A substantial body of research on families and mental illness has examined how caregiving processes are linked to the emotional health of family caregivers (10–13). A consistent pattern of findings underscores that more psychiatric symptoms of the patient, more behavior problems of the patient, and more caregiving demands are associated with higher levels of caregivers’ feelings of burden and psychological distress. However, there has been a paucity of research on the emotional health of Latino caregivers of a family member with mental illness. The few studies that have been conducted with Latino family caregivers have found that these caregivers experience burden and psychological distress at levels similar to those of European-American family caregivers (14–16). However, in studies of families caring for persons with other disorders, such as Alzheimer’s disease, dementia, or mental retardation, Latino caregivers have consistently reported higher levels of depression than European-American caregivers (17). Literature on Latino family caregivers and mental illness suggests that although Latino family caregivers are likely to be highly engaged and display warmth toward patients, the caregivers are also experiencing substantial stress and burden related to caregiving. Thus research is needed that focuses on Latino caregivers’ emotional health. In this study, we examined levels of depressive symptoms among Latino caregivers of family members with schizophrenia and the correlates of depressive symptoms in this population by using a stress-process model. In research on the emotional health of family caregivers of older adults, stress-process models have been used that include context variables (for example, demographic characteristics), stressors, and caregiver appraisals, such as subjective burden (18,19). Taking into account context variables, caregiving stressors (for example, patients’ psychiatric symptoms) are hypothesized to impact caregivers’ emotional distress both directly and through mediating factors, such as caregivers’ appraisals (19). Following this model, we hypothesized that stressors (patients’ positive symptoms) would be related to caregivers’ depressive symptoms after taking into account context variables (for example, demographic characteristics). Because positive symptoms are often linked with interpersonal conflict and disruption of daily routines, they can be considered objective stressors for family caregivers. Second, we hypothesized that caregivers’ appraisals (subjective burden) would mediate the relation between patients’ positive symptoms and caregivers’ depressive symptoms. In other words, high levels of positive symptoms would be related to more burdensome appraisals by caregivers, which would, in turn, be related to higher levels of caregivers’ depressive symptoms. We also examined the role of caregivers’ perceived stigma in the stress-process model. Stigma is characterized as a source of shame that is cast onto individuals with mental illness by society (20,21). Caregivers who have a relative with a high level of publicly conspicuous positive symptoms may also experience stigma and, in turn, higher levels of depressive symptoms. Hence, we hypothesized that stigma would be positively related to caregivers’ psychological distress. Furthermore, stigma may have subjective appraisal components such that some family caregivers may appraise schizophrenia symptoms as being more stigmatizing than other family caregivers would rate them. Hence, we also hypothesized that stigma would mediate the relation between patients’ symptoms and caregivers’ depressive symptoms. Sociodemographic correlates of depression among Latinos include socioeconomic status, female gender, older age, and marital status (22,23). Thus they were incorporated in this study as context variables. Previous studies of family caregivers of persons with mental illness have examined the impact of psychiatric symptoms on stigma, subjective burden, and depression, each as separate outcomes. Our study makes a unique contribution to the literature on family caregivers by examining the role of caregivers’ burden and stigma as mediators between patients’ positive psychiatric symptoms and caregivers’ depression. Furthermore, we examined these processes among Latinos, who have been underrepresented in caregiving burden research. Research questions for the study presented here include the following. What characteristics of caregivers and patients (context variables) are related to caregivers’ depressive symptoms? Are patients’ psychiatric symptoms (stressors) as well as caregivers’ burden and caregivers’ stigma (appraisals) positively related to caregivers’ depressive symptoms? Does burden, stigma, or both mediate the relation between caregivers’ stressors (patients’ psychiatric symptoms) and caregivers’ depressive symptoms?