Behavioral And Mental Disorders



Mental and behavioral disorders are common and affect more than 25% of all people at some time during their lives. One in four families is likely to have at least one member with a behavioral or mental disorder. It is estimated that mental disorders contribute a large share to the global disease burden and account for 33% of the years lived with the disability worldwide.(Jai Rakini Aruna,2007)

The Global Burden of Disease study found mental disorders to be the fourth leading cause of disability. Depression alone was the single leading cause of global disability. For a better treatment family cohesion is essential. In the primitive societies, mental illness was thought to be caused by evil spirits. As time passed, professionals and society understood the importance of the family members participating in the care of the mentally ill patients in the hospital. An extremely significant innovation that has been extensively validated in recent times was the bold experiments of Dr Vidha Sagar at the Amritsar Mental Hospital. The approach was the comprehensive involvement of families in the care recovery and aftercare of psychotic patients and facilitated their acceptance and turn to their own homes in the community. These efforts continued in the 1960s at NlMHANS and culminated in the opening of the family ward. Today, there is widespread international acceptance of such approaches, which are known under the rubric of family interventions.(Dr.Lalitha ,2007)

The family has always been recognized as an important factor both in the genesis and prognosis of mental illness. Initial studies generally focused on the possible etiologic role of the family, but the perspective has now changed to incorporating the family as a “reactor� to mental illness of a member. This has led to interest in various problems that arise from the patient’s presence at home such as financial difficulties or marital disharmony. The sum total of these problems or difficulties which affect the significant others of a psychiatric patient is referred to as social or family burden.

Care for severely mentally ill individuals may carry a heavy burden, more so than the care for other disabled individuals such as mentally retarded people. It is particularly true for close family members such as parents, many of whom take care of their mentally ill children for long. Such burden manifests in reduced caregiver wellbeing which admittedly depends in part on caregiver factors such as care-giving style. Moreover, such burden may manifest in reduced wellbeing of the mentally ill individuals themselves, for example, due to impaired caregiver support

1.1Need for the study: Living with and caring for an individual with a psychiatric disorder seems inherently stressful. Relatives of psychiatric patients report a wide range of reactions to their situation. On the whole, these family members endorse significantly higher level of psychological distress than the general population.

Mental illness has long been a problem in modern society. The treatment and rehabilitation of clients with mental illness are a heavy burden on the government. It is estimated that two to three persons in every thousand adults suffer from serious mental illness such as affective disorders and schizophrenia. Studies have shown that in taking care of the mentally ill, the family caregivers have to face the following stress and burdens: Feelings of insecurity, sorrow and worry, potential harm and aggression, stigmatization by relatives and friends, psychiatric emergencies and relapse, dependence, social isolation, fear of the future.

Deinstitutionalization, restricted hospital admission and reduction of length of inpatient treatment also change the situation of relatives. Nowadays they are much more involved in the care of patients. Many caregivers of a person with schizophrenia suffer from ongoing distress whereas professionals tend to underestimate family burden. Thus caregivers feel ignored by mental health professionals. This divergent perception underlines the importance of quantitative studies on family burden.

Health professionals and mental health nurses have an important duty to acknowledge the burden of caregivers. They are in a position to render support and refer them to get further support through social workers and community agencies. Such measures would ensure family wellbeing for families with mentally ill patients. For that the mental health nurse needs to assess the burden of caregivers and to identify the support they receive during their period of care-giving in the hospital. Many studies have been done on the burden that relatives experience when living with a psychiatric patient.

1.2 Statement of the problem


1.3 Objectives

1.3.1. Assessment of the stress level of primary caregivers of mentally ill patients.

1.3.2. Assessment of level of coping measures adopted by caregivers of mentally ill patients.

1.3.3. Effect of coping measures in management of stress among the primary caregivers of mentally ill patients.


1.4.1. The caregivers will have some degree of stress related to the care of mentally ill relatives.

1.4.2. Promotion of coping measures will help the caregivers to manage the stress.

1.5 Hypotheses

H1: There will be reduction in stress among caregivers of mentally ill by using coping measures.

1.6 Operational Definitions

1.6.1. Promotion: Promotion is the process to reduce stress and improve psychological wellbeing among care givers by adopting various coping measures.

1.6.2. Coping measures: various strategies taken to decrease the stress level.

1.6.3. Primary Caregiver: It refers to a person who spends most of the time in meeting the physical& psychological need of the mentally ill.

1.7 Promotion of Coping Measures Related to Caregivers Stress Among Mentally Ill Patients: The conceptual framework for this study derived from General System Theory (Ludwig Von Laffy, 1968).According to general system theory, a system is asset of components or units interacting with each other with in a boundary that filters the kind and rate of flow of inputs and outputs to and from the systems. (Fig 1.1)

In this study, the input is the assessment of level of stress and assessment of coping measures in caregivers using a questionnaire. Throughput is the active phase where a planned teaching programme administered to the caregivers on ways of coping measures to manage stress. Output is the reassessment of level of stress.

1.8 Projected Outcome

Coping measures will improve the caregiver’s ability to cope with stress and perform better in their daily activities.



A Literature review is a critical summary of research on a topic of interest often prepared to put a research problem in context .A literature review helps to lay the foundation for a study and can also inspire new research ideas.

A systematic review of literature and appraisal of all the relevant scholarly literature on the specific topic involves an in depth study. An extensive review of literature was done on the related research and non research literature.

The literature was reviewed under the following areas and analyzed:

2.1. Literature related to caregivers stress

2.2. Literature related to coping measures used to reduce stress

2.1 Literature related to Caregivers stress

A comparative study was conducted among Euro- Americans and Latinos to study the relationship between family burden of schizophrenia and socio cultural context. Findings suggest differences in levels of family distress in relation to socio-cultural factors like gender, ethnicity, diagnosis, and living situation, across cultural and diagnostic groups. (JH Jenkins and JG Schumacher1999).

Two Indian comparative studies were conducted in different states of India on the caregivers’ burden of schizophrenia and OCD patients. Ninety two First degree relatives/ spouses were compared. One study showed higher burden in OCD group that was high among spouses than relatives of schizophrenia group .One more study showed higher burden in schizophrenia than OCD. (Guru raj .et. al., 2008)

The study was conducted to measure the perception of burden by caregivers of patients with schizophrenia at Institute of Mental Health and Hospital, Agra. the Burden Assessment Schedule (BAS) was correlated to spouse, physical and mental health, external support, caregiver's routines, support to patient, responsibility-taking, other relatives, patient's behavior and caregiver's strategy. A number of sample is thirty four caregivers of patient with schizophrenia. A low positive correlation was found between urban domiciles and support of the patient and the caregiver's routine. There was a low positive correlation between age less than 30 years and the physical and mental health of the caregiver, and with taking responsibility. (Sunil Srivastava 2005)

This comparative cross-sectional study assessed family burden among caregivers of patients with OCD and schizophrenia. in an Indian setting. Findings shows Indian families experience significant degrees of burden in the care of their relatives with OCD and schizophrenia. Relatives' demographic characteristics did not influence burden severity. Illness severity and patients' disability had a direct positive relationship with perceived family burden.this study suggest to develop local needs based support programmes for families of patients with psychiatric disorders in India. (Rammohan A et

al., 2002)

A case study was investigated the incidence of chronic sorrow in parents of chronically mentally ill children like schizophrenia or bipolar disorder. Convenience samples of 10 parents (four couples and two mothers) of adult children were interviewed using the Burke/NCRCS Chronic Sorrow questionnaire (Caregiver Version). Results showed that 8 out of 10 parents experienced chronic sorrow and suggested that healthcare professionals could assist them by providing information about their child's illness and by involving them in the treatment process. (Georgene G. Eakes2004).

A study was examined on psychological distress among Latino family caregivers of adult with schizophrenia. The interview was done by using Zarit Burden Scale. The results shows that younger caregiver age, lower levels of caregivers' education, and higher levels of the patients' mental ill0ness symptoms were predictive of higher levels of caregivers' depressive symptoms. Caregivers' perceived burden mediated the relation between patients' psychiatric symptoms and caregivers' depression. (Sandy. M. Magana et al,1997).

The comparative study was conducted to study the caregivers of mentally ill relatives to explore the relationship between gender and perceived levels of burden. Ninety-seven caregivers (76 women, 21 men) were interviewed. Women were found to experience a greater sense of burden and frustration than men in caring for their mentally ill relatives. The authors concluded that women encountered a wide range of difficulties centered around family and child rearing. (Ascher-Svanum and Sobel,1989).

A study explores the influences of selected social and psychological factors that are associated with perceived caregiver stress among 263 primary caregivers of the elderly in Allahabad City in northern India. The results indicate that although male caregivers' perceived stress depends only on the size of the role overload, female caregivers' perceived stress depends on the interrelationship between the size of the role overload and adherence to Asian cultural norms. (Rashmi Gupta et al., 2010).

2.2 Literature Related to Coping measures to Reduce caregivers stress

A analytical study conducted at Iran to identify caregivers at risk for adverse health effects associated with care giving, the stress, coping, health. The sample size used was 500 primary caregivers of patients with bipolar disorder. The results shows Burdened caregivers had less coping levels, lower mastery and social support. Effective and stigmatized groups had better health outcomes and less service use than the burdened group over time; stigmatized caregivers had poorer self-care than effective caregivers. (Perlick DA et al.,2008).

A descriptive study was examined the effectiveness of a stress relief initiative for primary caregivers of adolescents with intellectual disability (ID) at Taiwan. Seventy-seven primary caregivers of people with ID were selected the study, which involved participation in one stress management workshop (intervention group only) and both groups reading an education booklet on stress management. They found that 22.1% of caregivers in the study were at high risk of depressive stress and in need of mental health consultation; this prevalence was nearly six times that of the general population. The study results show that a "face-to-face" workshop is an effective way to decrease levels of depressive stress. (Hu J et al., 2010)

The pilot study was conducted to assess the level of stress experienced by caregivers of brain tumor patients and to examine both their interest in and preferences for stress reduction programs at North Carolina in USA. Convenience sampling technique was used. The sample size is 60 adult caregivers. The study examined the caregivers' level of stress, beliefs, past experiences, and preferences in regard to stress reduction programs. A seventy two percent of the caregivers reported elevated stress levels , eighty seven percent caregiver believed that stress reduction techniques can help reduce stress ,eighty one percent caregiver were interested in learning about programs to reduce stress . Overall, sixty five caregivers wanted to receive information about stress reduction programs and seventy three percent caregivers were interested in programs such as exercise to reduce stress. Overall, fourty four percentages of caregivers were interested in participating in the various stress reduction programs presented to them in this study. These data provide further evidence that caregivers experience elevated levels of stress and are willing to learn more about and participate in programs to reduce stress .(Keir.ST,2007).

The descriptive study was to examine the effects of music, progressive muscle relaxation (PMR), and music combined with progressive muscle relaxation on the reduction of anxiety, fatigue, and improvement of quality of life in family hospice caregivers at university of Kansas in USA. Sample size is 32 .The duration of study was 2 weeks. Paired t test indicated that the control and PMR group exhibited a significant difference in pre and posttest quality of life scores. Results shows that a significant correlation between anxiety and quality of life, anxiety and fatigue, fatigue and quality of life. ( ChoiYK,2010).

A mail survey was conducted using a representative sample of 998 employed Chicago residents who provided informal care for at least one person. Ordinary least squares regression models were computed to examine the relationship between caregiver burden and drinking outcomes. Results suggest that caregivers who experience social and emotional burdens related to care giving are at risk for problematic alcohol use and warrant attention from health care and mental health service professionals. (Rosependa KM .et al,2010).

A comparative study conducted in Australia to investigate the relationship between depression, nutritional risk and dietary intake in a population of older caregivers. Mailed questionnaire with sub group participating in a home based interview was used. Seventy-six community dwelling caregivers aged 50 years or over from Victoria, Australia. The data collected related to weight, height, hours of care, depressive symptoms, nutritional risk and appetite, dietary intake and shopping, cooking and meal consumption habits. Results shows thirty two percent of caregivers had depressive symptoms twenty one percent were at risk of malnutrition and twenty one percent reported their appetite was bad. Caregivers with depressive symptoms (32%) compared to those with no depressive symptoms (53%) had a poorer appetite (p < 0.05). Of the 20 caregivers who participated in the home interview, 25% reported they ate their meals alone. A results suggest older caregivers had depressive symptoms, were at risk of malnutrition and had poor appetites, although the majority were overweight or obese.(Torres SJ,et al2010)

A randomized comparative trial was undertaken comparing yoga with relaxation in South Australia. One hundred and thirty-one subjects with mild to moderate levels of stress. One hour sessions of relaxation or hatha yoga for 10 weeks .Following the 10 week intervention stress, anxiety and quality of life scores improved over time. Yoga was found to be as effective as relaxation in reducing stress, anxiety and improving health status. Yoga was more effective than relaxation in improving mental health. Vitality, social function and mental health. Yoga appears to provide a comparable improvement in stress, anxiety and health status compared to relaxation.(Smith C et al .,2007).

A pilot study of a yoga and meditation intervention for dementia caregiver stress. Twelve older female dementia patient family caregivers were participated. This study planned to help caregivers cope with stress. Pre test and post test revealed statistically significant reductions in depression and anxiety and improvements in perceived self-efficacy. These findings suggest that yoga and meditation may be a feasible and effective intervention for family caregivers and may improve affect, coping, physical well-being, and stress management.(Waelde L C et al.,2004).



This study is designed to promote the coping measures to manage stress among caregivers of mentally ill patients. The steps of quantitative research process are adopted for conducting the study. It includes the research design, setting, population and sampling, sample size, determination, instrument and tools for data collection, variables of the study and techniques of data collection, methods of data analysis and interpretation and report of the pilot study.

3.1 One Group Pre Test and Post test Design: The research design used in this study is one group pre and post test design. This is a quasi experimental design. Here the test acts as a measurement tool for the evaluation effect on post test. This is a straight forward design in which there is only one pre assessment and one post assessment, with only one set of intervention. The level of stress of caregivers is initially assessed, based on which coping measures implemented after which stress level of caregiver is reassessed to know the impact of coping measures on reduction of stress.

Figure 3.1

One group pre test and post test design

Pre test (Assessment of coping measures and level of stress)

Intervention (Administer Coping measures and relaxation technique)

Post test

(Post assessment of level of stress)

3.2 Setting of the study: The study was conducted at vazhikatti mental health centre, Coimbatore. The primary caregivers of mentally ill patient who were admitted in the vazhikatti centre were selected.

3.3 Population and sampling: All primary caregivers of mentally ill patients admitted at vazhikatti centre were taken for study during the period between 29.06.10 to 25.07.10.

3.4 Criteria For Sample Selection:

3.4.1 Inclusion criteria

Primary Caregivers of mentally ill patients those who are admitted in the hospital.

Caregivers who could understand & speak English,& Tamil

3.4.2 Exclusion criteria

Caregivers like paid home nurses, paid house maid, were not included in the study.

3.5 Variables of the study:

3.5.1 Independent Variables: The independent variables in this study are the structured teaching and demonstration of relaxation technique to the caregivers on ways of coping measures to manage stress. Demographic variables such as age of the caregiver, sex, religion, educational qualification, occupation, relationship of caregiver with patient, monthly family income, source of income, bread winner of the family, source of expenses, type of family, diagnosis of the patient, duration of illness of the client, frequency of hospital visit and person taking care of the children are all independent variables.

3.5.2 Dependent variables: The dependent variables of the study are stress level among the caregivers before education and stress level after education.

3.6 Instrument for data collection: The instrument used for the collection of data was rating scale for assessing the level of stress and self coping measures adopted by the caregivers.

Section 1:The demographic data includes age of the caregiver, sex, religion, educational qualification, occupation, relationship of caregiver with patient, monthly family income, source of income, bread winner of the family, source of expenses, type of family, diagnosis of the patient, duration of illness of the client, frequency of hospital visit and person taking care of the children.

Section 11: This section also has a checklist which include 14 items related to self coping measures adopted by the caregivers when scores increase their coping skill would be rated as adequate, if it less than 50 scores rated as inadequate coping.

Scoring: The scores are interpreted as follows.

Level of stress

Level of self coping

Scoring Interpretation

Scoring Interpretation

1-22 Very Mild Stress

23-44 Mild Stress

50-115 Adequate coping

45-66 Moderate Stress

<50 Inadequate coping

67-88 Severe Stress

Section 1I1: The rating scale includes 22 items. Each question has four possible responses as never, rarely, sometimes, quite frequently and nearly always. The scoring given as 0, 1, 2, 3, 4.The level of stress categorized as very mild ,mild, moderate, and severe.

3.7 Reliability and Validity of Instrument And Tools for Data Collection:The tools was prepared with the help of literature review and expert guidance. The reliability and validity of tool was tested through pilot study.

3.8 Data Collection Procedure: The main study was conducted from 24.06.2010 to 25.07.2010. Primary care taker were selected. The questions were read in tamil by the investigator and responses were recorded. Each interview was conducted on one to one basis which lasted for 20 minutes. Education was given regarding definition of stress, signs and symptoms of stress, and various stress management techniques was conducted for one hour using audio visual aids (charts),following this on next day one hour allotted for demonstration of relaxation exercises. Care givers were reinforced to adopt the coping measures to manage stress and encourage doing relaxation exercises. Reassessment was done after 10 days of education using the same check list.

3.9 Techniques Of Data Analysis: The data collected through various methods has been compiled and by adopting appropriate statistical techniques inferences were drawn. After clarification, data frequencies are calculated for demographic, social and economic variables to determine the distribution pattern of the caregivers into each category. Similarly frequencies are calculated for level of stress among caregivers. The distribution pattern is depicted through appropriate graphical methods. The results are inferred through statistical technique like paired ‘’t’’ test and simple correlation coefficient. The comparison of level of stress before and after coping measures is interpreted through paired ‘’t’’ test and the influence of independent variable like family income, Calculated through simple correlation coefficient.

3.9.1 Paired‘t’ Test:

This was adopted to find out the significant difference between pretest score and post test score. The formula is

d =Difference between pretest and post test score.

d =Mean difference pretest and post test score.

SD=Standard deviation of pretest and post test score.

=Root of number of samples.

3.9.2 Karl Pearson’s Co-Efficient of correlation:

This was calculated to find out the influence of independent variables on the dependent variable.

The formula is

X =( x – x )

Y =( y – y )

X =Independent variable.

Y =Dependent variable.

3.10 Report of the Pilot Study: The pretest was conducted by using the planned checklist for the caregivers. A planned teaching programme was conducted for one hour. Next day demonstration of relaxation exercises were given for one hour separately for each one. 7 to 10 days when discharge day posttest was conducted and results were analyzed based on the scores.

During the analysis of the result it was found that caregivers stress level was reduced from moderate to mild stress level and mild level stress to very mild level stress after the implementation of coping measures.