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The effects of caregiver emotional stress on the depressive symptomatology of the care recipient a

a

Deborah B. Ejem , Patricia Drentea & Olivio J. Clay a

b

Department of Sociology, University of Alabama at Birmingham, Birmingham, AL, USA

b

Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA Published online: 28 May 2014.

Click for updates To cite this article: Deborah B. Ejem, Patricia Drentea & Olivio J. Clay (2015) The effects of caregiver emotional stress on the depressive symptomatology of the care recipient, Aging & Mental Health, 19:1, 55-62, DOI: 10.1080/13607863.2014.915919 To link to this article: http://dx.doi.org/10.1080/13607863.2014.915919

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Aging & Mental Health, 2015 Vol. 19, No. 1, 5562, http://dx.doi.org/10.1080/13607863.2014.915919

The effects of caregiver emotional stress on the depressive symptomatology of the care recipient Deborah B. Ejema*, Patricia Drenteaa and Olivio J. Clayb a

Department of Sociology, University of Alabama at Birmingham, Birmingham, AL, USA; bDepartment of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA

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(Received 13 November 2013; accepted 11 April 2014) Objectives: Depression is a leading mental health issue affecting elderly individuals worldwide. Previous research widely neglects caregiver emotional stress as a probable contributing factor of depression in the elderly. This study investigated caregiver emotional stress as a chronic life stressor of an elderly care recipient using the life stress paradigm as the theoretical foundation. Methods: The relationships between caregiver emotional stress and care receiver depressive symptoms, as well as other social and psychological mediation factors, were investigated using the 2004 wave of the National Long-Term Care Study (NLTCS). The NLTCS is a nationally representative longitudinal study used to identify frail and disabled elderly Medicare recipients living in the United States. The analytic sample of this study included 1340 caregivercare receiver dyads who were asked a series of questions concerning their mental health (i.e. emotional stress and depressive symptoms), as well as the availability of social and psychological resources. Results: Overall, the results showed that high levels of emotional stress reported by the caregiver were associated with a higher likelihood of the disabled care receiver reporting depressive symptoms. Conclusion: The findings of this investigation point to the importance of studying caregivers and care receivers as dyads as the stress associated with the caregiving role affects each member. Keywords: life stress paradigm; stressors; resources; caregiving; National Long-Term Care Study

Introduction Depression is a leading mental health issue among elderly individuals internationally and is associated with impaired social functioning and health-related quality of life (Barkow et al., 2003; Cole & Dendukuri, 2003; Strine et al., 2008). With national projections estimating that older adults are the fastest growing population, geriatric depression has become a matter of public concern (Navaie-Waliser, Spriggs, & Feldman, 2002).Worldwide, the prevalence rates of elderly depression range from 10% to 55% (Rajkumar, Thangadurai, Senthilkumar, Prince, & Jacob, 2009). In fact, the World Health Organization (WHO) ranks depression as the leading cause of disability, and by the year 2021, the second most burdensome mental health disease worldwide (WHO, 2001). Because depression is such a problem, a substantial amount of research is devoted to the causes of depression of the elderly. Some studies on elderly depression suggest the factors such as comorbid conditions, being female, perceived social isolation, social disconnectedness, pain, and bereavement may cause depression in this group (Cole & Dendukuri, 2003; Cornwell & Waite, 2009; Jakobsson, Hallberg, & Westergren, 2004). However, most of the interest in elderly depression is geared toward studying how caregiving for an elderly person can cause adverse mental and physical health. This is of salience because there are so many individuals who provide informal care worldwide. Caregiving is physically and emotionally cumbersome, and can lead to mental and physical health *Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis

decline for the person tasked with providing care (Rigby, Gubitz, & Phillips, 2009). Thus, the effect of the caregiver’s emotional state on the mental health of the care receiver must also be considered. This is the intention of this study, to evaluate the effects of emotional stress of an informal caregiver on the depressive symptomatology of a care recipient. The emotional stress of the caregiver is defined as the psychological load that one experiences when providing informal care. Other approaches for understanding depression in elderly Other areas of study find that negative caregiving characteristics such as resentfulness, discourteousness, reluctance, and criticism led to negative reactions by the care recipient (Newsom, 1999). These negative reactions resulted in issues with psychological well-being such as lowered self-esteem and perceived control (Newsom, 1999). More recently, Grant et al. (2013) found that among stroke survivors, caregiver well-being (i.e. life satisfaction and depressive symptoms) mediated the relationship between impairment and depression. However, previous research fails to examine the stress experienced by the caregiver as a chronic life stressor of a care receiver that directly causes adverse mental health. Rather, characteristics of caregivers were studied only as moderators and mediators of psychological well-being (Grant et al., 2013; Newsom, 1999). For these reasons, the following research is important because it intends to fill a substantial

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gap in gerontological research by systematically studying the direct and indirect effects of caregiver emotional stress on the depression of the elderly care recipient. We use the life stress paradigm as our theoretical foundation. The life stress paradigm is a useful theory in evaluating the effects of depression of a caregiver on the mental health of the elderly who receives his/her care because it provides a general theoretical link between one’s daily encounters and health outcome. The life stress paradigm developed by Lin and Ensel (1989) states that life stressors have a negative effect on one’s well-being. However, resources, both social and psychological, can mediate the effect that these life stressors have on health (Lin & Ensel, 1989). That is, one’s social and psychological resources can reduce the negative effect that life stressors have on mental and physical health outcomes (Lin & Ensel, 1989). Negative caregiving relationships as a form of life stressor Life stressors can result from two sources, traumatic life events or recurring and enduring life problems termed as chronic strain (Pearlin, 1989). The latter, the most influential in this study, involves ‘enduring problems, conflicts, and threats that many people face in their daily lives’ (Pearlin, 1989, p. 245). One form of chronic strain is role restructuring, in which the relationships in a role set undergo change. This is a salient issue for the elderly. As individuals age, they begin to relinquish their previous roles to individuals close to them (Roth, Perkins, Wadley, Temple, & Harley, 2009). This can result in distress and subsequent negative physical and mental health conditions, such as depression, for the individuals who assume the additional role as caregiver. An individual who becomes depressed because of his or her roles as a caregiver, consequently suffers worse physical functioning (Roth et al., 2009). This decline in functioning can result in a decrease in the level of care received by the care recipient. Social support as a mediator of health outcomes Social support, which Lin and Ensel (1989, p. 383) define as ‘the process by which resources in the social structure are brought to bear to meet the functional needs in routine and crisis situations,’ can improve one’s health and his/ her potential to counter the negative effects of life stressors (Clay, Roth, Wadley, & Haley, 2008; Drentea, Clay, Roth, & Mittelman, 2006). As previously argued, intimate relationships have the potential to affect the mental health of the individuals involved in them (Lin & Ensel, 1989). These intimate relationships can also have a mediating effect on the mental health of the individual who receives the support. The mediating or intervening effect occurs when the incorporation of these intimate relationships lessens the effect of the negative life events on mental and physical health (Lin & Ensel, 1989). Seeking support from other family members, neighbors, church members, and voluntary associations can reduce the effects of the

negative caregiving relationship on the mental health of the elderly. Psychological resources and chronic life stress Pearlin and Schooler (1978) first defined psychological resources as ‘personality characteristics that people draw upon to help them withstand threats posed by events and objects in their environment’ (p. 5). Psychosocial resources such as feelings of personal competence, locus of control, self-esteem, hardiness, and mastery have a mediating effect on the mental and physical ailments caused by life stressors (Lin & Ensel, 1989). Physiological resources and stress The physiological environment also has an effect on the well-being of an individual (Lin & Ensel, 1989). Physiological stress such as clinically diagnosed illnesses and physical symptoms such as the presence of disabilities with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are said to have a negative effect on well-being. In addition, physiological resources, such as diet, exercise, and healthy lifestyle practices such as refraining from drugs, tobacco, and alcohol, are expected to have a positive effect on well-being (Lin & Ensel, 1989). Life stressors’ negative effect on social and psychological resources Finally, there is strong evidence that a temporal link between life stressors and the resource availability exists (Ensel & Lin, 1991). ‘Causally, life experiences precede resources. That is, resources become meaningful only after an individual has experienced stressful conditions or situations’ (Ensel & Lin, 1991, p. 325). In other words, the presence of life stressors diminishes the amount of resources available to an individual. Therefore, a negative caregiving relationship has a negative effect on the resources, both social and psychological, that the care recipient has. Hypotheses Based on a modified version of the life stress paradigm, the following hypotheses have been devised: (1) Higher levels of caregiver emotional stress will be associated with higher levels of care receiver depressive symptoms. (2) Higher levels of social and psychological resources available to a care recipient will be associated with lower levels of care receiver depressive symptoms. Methods Data and sampling We used secondary analysis of the most recent wave, 2004, of the National Long-Term Care Survey (NLTCS)

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Aging & Mental Health to assess the relationship between the level of emotional stress of a caregiver and the depressive symptomatology of a care recipient. The NLTCS is a nationally representative longitudinal study used to identify frail and disabled elderly persons living in the United States. The NLTCS was first collected in 1982; thereafter, five other waves were collected at five-year intervals (1984, 1989, 1994, 1999, and 2004). The target population of the study was Medicare recipients aged 65 or older who are disabled and living in the community, and disabled and living in an institution. This project uses a stratified, two-stage clustered design (Duke University Center for Demographic Studies, 2006). The response rate ranged from 87.7% to 97.6% over the five waves of the survey (Freedman et al., 2004; Manton & Gu, 2001). The NLTCS was administered through scheduled structured telephone and in-home interviews in which respondents were asked about physical disabilities, medical conditions, family support, active life expectancy, ADLs, IADLs, cognitive functioning, and the use of formal and informal caregiving (Duke University Center for Demographic Studies, 2006). Primary informal caregivers were also surveyed. Informal caregivers were identified based on information provided by the NLTCS respondents. An eligible caregiver is one who provides unpaid help with at least one ADL or IADL for at least one hour in the week prior to NLTCS community survey (Wolff & Kasper, 2006). When there was more than one individual who met the caregiver criteria, a primary caregiver was elected based on the individual who spent the most time providing help (Wolff & Kasper, 2006). This caregiver was surveyed three months after being initially identified by the NLTCS via the supplemental National Informal Caregivers Survey (NICS). In this survey, caregivers were asked about the type of help that they provide for the care recipient, as well as questions on physical strain, emotional stress, and financial hardship caused by the caregiving relationship (Wolff & Kasper, 2006). The 2004 wave was used to investigate the effects of a stressed caregiver on the depressive symptomatology of the care recipient. The initial 2004 wave included a total of 20,474 respondents. To obtain the analytic sample, the sample was filtered by three questions. First, this sample was restricted to individuals who answered all of the depression questions. This reduced the analytic sample to 4355 respondents. Second, the sample was restricted to respondents who reported having a primary caregiver (reducing the sample to 1605). Finally, all caregivers who did not complete the interview were excluded, resulting in an analytic sample of 1340 respondents. Missing values were imputed on all variables except for the dependent variable using the linear interpolation method in SPSS. Linear interpolation uses ordinary least squares (OLS) regression to predict missing values and impute them. Only a small percentage of the data is missing for caregiver emotional stress, care receiver education, ADLs, IADLs, self-rated health, caregiver education, and social and psychological resources. The percentage of missing values for all variables ranges from less than 1%5%.

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Measurement The outcome of interest, depressive symptomatology of the care recipient, was measured by a modified version of the center for epidemiologic studies depression (CES-D) scale (Radloff, 1977). This is a three-item scale in which the NLTCS respondents were asked questions about recent depressed mood (a ¼ .713). The responses were yes (coded as 1) and no (coded as 0). The scale ranged from 0 to 3. The majority (74.5%) of the sample expressed no depressive symptoms. Thus, the sample was strongly positively skewed, and depression was dichotomized. Individuals who reported no depressive symptoms were given a score of 0, while anyone who reported any depressive symptoms was given a score of 1. The main predictor in this study is emotional stress of the caregiver. Using the NICS portion of the data-set, emotional stress was measured by an ordinal-level question asking the caregiver to describe how emotionally stressful caregiving was for them. The response options for this ordinal variable were 1 (not at all stressful), 2 (a little stressful), 3 (moderately stressful), 4 (pretty stressful), and 5 (very stressful). The care receiver’s social support was measured by two scales. Both scales are derived from the RAND Social Health Battery (Donald, Ware, Brooks, & Davies-Avery, 1978). The first scale is based on questions that ask about frequency of contact with family in the past month; the second is based on frequency of contact with friends in the past month. Response options for this scale were none (coded as 0), once or twice (coded as 1), 35 times (coded as 2), 610 times (coded as 3), 1129 times (coded as 4), and 30 or more times (coded as 5). Both scales are twoitem scales, with scores ranging from 0 to 10. A score of 0 represents no contact with family or friends, and a score of 10 represents daily contact with family or friends. The correlation coefficients of the family and friend contact scales were .502 and .510, respectively. To measure the social participation of the care receiver, two questions were asked about religious service attendance and participation in other organizations during the past month. Response options for both questions were yes (coded as 1) and no (coded as 0). The cognitive functioning of the care receiver, a psychological resource, was measured using the Short Portable Mental Status Questionnaire (SPMSQ) (Pfeiffer, 1975). Specifically, the respondents were asked questions, such as ‘What is the date today?’ and ‘What day of the week is it?’ The correct responses were scored as 1 and the incorrect responses were scored as 0. This scale is a 10-item scale, with scores ranging from 0 to 10; 10 represents the highest level of cognitive functioning (a ¼ .741). Important descriptive covariates include the age of the care recipient, age of the caregiver, sex of the caregiver and care recipient (female ¼ 1), race of the care receiver (black ¼ 1, nonblack ¼ 0), education level of both the caregiver and care recipient, and self-rated health of the care receiver (poor health ¼ 1, fair health ¼ 2, good health ¼ 3, and excellent health ¼ 4). The relationship of the caregiver to the care receiver (spouse as the reference group) was controlled. The 26 categories were collapsed

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into 5 categories: spouse, son/daughter (this includes sonin-law, daughter-in-law), mother/father (this includes mother-in-law and father-in-law), brother/sister (this includes brother-in-law and sister-in-law), and all other relationships (this category comprised other male relative, other female relative, male friend, female friend, female neighbor, employee, someone from helping organization, institution/assisted living facility, legal guardian, and someone else). The mother/father group was omitted from the analysis because there were no respondents in this group. Also, physiological stress was controlled for by determining the number of ADLs and IADLs of the elderly care receiver. This is measured based on Katz and Akpom’s (1976) index of ADLs and Lawton and Brody’s (1969) IADLs. The scores for both scales range from 0 to 7; 0 representing that the respondent was not disabled with any IADLs or ADLs, and 7 representing that the respondent was disabled with all IADLs or ADLs. The Cronbach’s alpha for ADL and IADL scale was .778 and .827, respectively. Analytic procedure To evaluate the direct and indirect effects of emotional stress on care receiver depressive symptoms, bivariate and multivariate analyses were conducted. First, the outcome variable (care receiver depressive symptoms) was regressed on each of the variables of interest, including the main predictor variable (caregiver emotional stress) in a series of bivariate analysis. Next, multivariate analyses were conducted to examine the association between caregiver emotional stress and care receiver depressive symptoms, using the significant covariates from the bivariate analyses as controls. Finally, significant social and psychological resources from the bivariate analyses were added to model to determine their mediating effects on the relationship between caregiver emotional stress and care receiver depressive symptoms. Results The average age of sample elderly respondents was approximately 81 years (see Table 1). The sample was predominately white (90.75%) and female (67.84%) with an 11th grade education. The majority of the sample (75%) did not report any depressive symptoms. Furthermore, this sample of elderly individuals reported having difficulty with 4.54 IADLs out of a possible of 7 and 1.31 ADLs out of 7. Additionally, the group scored very high on the SPMSQ with an average score of 8.62 on a 10point scale. On average, the respondents had moderate contact with family and friends. Finally, the majority of the sample attends church regularly, while they do not participate in civic organizations. The majority of caregivers were females (daughters or daughters-in-law) who had received a high school diploma or a General Educational Development (GED)1 certificate. In general, caregivers in this sample reported that caregiving caused them minimal stress. Table 2 follows with a comparison of care

recipients with and without depressive symptoms on the variable of interest. Table 3 illustrates that a relationship between caregiver emotional stress and care receiver depression exists after controlling for covariates. Specifically, Table 3 is a logistic regression of the effects of caregiver emotional stress, care receiver and caregiver demographics, selfrated health, and number of functional limitations of the care recipient on care receiver depressive symptoms. Caregiver emotional stress had a significant positive relationship with care recipient depressive symptomatology (OR ¼ 1.203, p ¼ .000). The education level, age, and the self-rated health score of the care receiver were negatively related to the depressive symptomatology of the care recipient (OR ¼ .952, p ¼ .016; OR ¼ .984, p ¼ .037; and OR ¼ .807, p ¼ .008, respectively). Thus, younger individuals with higher levels of education and those who reported being in better health were less likely to report depressive symptoms than those who were older with lower levels of education and who report being in worse health. Females were more likely to be depressed than males (OR ¼ 1.331, p ¼ .045) No other variables were significantly related to depression. Cognitive functioning was the only resource variable that had a significant bivariate relationship with care receiver depressive symptoms and was added to the previous model. Cognitive functioning of the care recipient had a negative relationship with their depressive symptomatology. Those with better cognitive functioning were more likely to not report depressive symptoms (OR ¼ .884, p ¼ .001). The relationship between caregiver emotional stress and depressive symptoms was reduced, but remained significant (OR ¼ 1.118, p ¼ .001). Thus, care recipient cognitive functioning only served as a partial mediator. Discussion Elderly depression is a leading mental health issue worldwide and is associated with impaired social functioning and health-related quality of life (Barkow et al., 2003; Cole & Dendukuri, 2003; Strine et al., 2008). Although there is a great deal of research that discusses the possible causes of depression, the current body of research neglects to study how the mental health of an aging individual can be negatively or positively affected by mental health of the individual that they depend on the most, their primary caregiver. The purpose of this study was to systematically evaluate the emotional stress of a primary caregiver as a possible stressor that results in adverse mental health in the aging population using the life stress paradigm. Overall, the results of this study support the hypothesis derived from the theoretical perspective that an emotionally stressed caregiver will be negatively associated with the mental health of a disabled care receiver. Even when health and social and psychological resources were taken into account, the emotional stress of a caregiver had a very significant effect on the depressive symptomatology of a disabled care receiver. However, the results only provided partial support for the social and psychological

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Table 1. Descriptive statistics for study sample, National Long-Term Care Survey, 2004 (N ¼ 1340).

Caregiver’s emotional stress score Age of care recipient Sex of care recipient Male Female Race of care recipient Nonblack Black Education of care recipient Caregiver sex Male Female Education of caregiver Relationship to the care recipient Spouse Son/daughter Brother/sister All other relationships Number of ADLs Number of IADLs Self-rated health score RAND Social Health Battery Frequency of contact with family Frequency of contact with friends Civic organization participation Has not recently participated Has recent participation Frequency of church attendance Has not recently attended church Has recently attended church SPMSQ score Care recipient depression Not depressed Depressed

Mean

Standard deviation

1.95 81.34

1.25 9.09

7.77

9.62

N

Percentage

431 909

32.16 67.84

1216 124

90.75 9.25

469 871

34.93 65.07

460 652 51 177

34.30 48.70 3.80 13.20

1133 210

84.40 15.70

3.48

3.11

1.31 4.54 2.50

1.76 2.21 0.87

6.20 4.10

2.91 2.94

792 551 8.62

resources serving as buffers in this relationship. In this covariate-adjusted model in Table 3, we see that caregiver emotional stress has a strong positive relationship with care receiver depression, even when you take into account the socio-demographic characteristics of both the caregiver and the care receiver. This provides support for hypothesis one which states that the emotional stress level of the caregiver will have a direct and positive association with the level of depression on the care recipient. Even when possible mediators are accounted for, as in Table 3, caregiver stress still retains a highly significant and positive relationship with care receiver depressive symptoms. The second hypothesis states that higher levels of social and psychological resources available to a care recipient will be associated with lower levels of depressive symptoms of the care recipient. There was partial support for this. Cognitive function, a psychological resource, was negatively associated with care receiver depressive symptoms. However, even when cognitive function was accounted for, caregiver emotional stress was still positively associated with depressive symptom.

59 41

1.77 999 341

74.60 25.40

This suggests partial mediation. All other mediators were not effective in reducing the negative effects of an emotional stress caregiver on the depressive level of a care receiver.

Limitations One of the most important limitations of this research project is the issue of selection bias. With a sample of elderly individuals whose average age is about 81, one can assume that individuals who were included in the sample were in some way different from those who were not. The individuals that were included in this sample are likely to be a resilient and healthier group, which would have a direct effect on their mental health. These issues are endemic to any longitudinal data-set, especially among the elderly. Data for the current investigation come from the 2004 NLTCS assessment. Caregiving research that uses more recent data has found similar findings. For example, Grant et al. (2013) found that caregiver well-being (i.e. life

Caregiver emotional stress score Age of care recipient Sex of care recipient Male Female Race of care recipient Nonblack Black Education of care recipient Caregiver sex Male Female Education of caregiver Relationship to the care Recipient Spouse Son/daughter Brother/sister All other relationships Number of ADLs Number of IADLs Self-rated health score Recent contact with family Recent contact with friends Recent civic organization participation Recent religious service attendance SPMSQ score

Variable 2.22 (1.392) 80.15 (9.261)

7.22 (3.410)

9.33 (3.070)

1.63 (1.838) 4.16 (2.174) 2.31 (0.903) 6.32 (2.893) 3.91 (2.920) 0.15 (0.359) 0.42 (0.494) 8.24 (2.004)

7.95 (3.491)

9.72 (3.120)

1.20 (1.714) 4.67 (2.206) 2.56 (0.855) 6.16 (2.915) 4.15 (2.943) 0.16 (0.364) 0.41 (0.491) 8.76 (1.657)

Mean (std)

Mean (std) 1.86 (1.185) 81.75 (8.995)

Depressive symptoms

No depressive symptoms

338(33.9) 480 (48.2) 39 (3.9) 139 (14.0)

122 (35.5) 172 (50.0) 12 (3.5) 38 (11.0)

126 (36.6) 218 (63.4)

311 (90.4) 33 (9.6)

905 (90.9) 91 (9.1)

342 (34.3) 654 (65.7)

97 (28.2) 247 (71.8)

n (%)

Depressive symptoms

334 (33.5) 662 (66.5)

n (%)

No depressive symptoms

Table 2. Comparisons for care recipients with and without depressive symptoms on variables of interest, National Long-Term Care Survey, 2004 (N ¼ 1340).

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.551 .000 .000 .000 .394 .185 .792 .793 .000

3.887 3.766 4.703 .853 1.327 .263 .262 4.760

.442 .049

.801 .001

(2.107)

(0.590) 1.968

(0.063) 3.383

.068

.000 .005

4.650 2.883

(3.337)

p

t (a2)

60 D.B. Ejem et al.

Aging & Mental Health Table 3. Logistic regression analysis of caregiver emotional stress, demographics, and self-rated health as predictors of care recipient depressive symptoms, National Long-Term Care Survey, 2004 (N ¼ 1340).

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Caregiver emotional stress Age of care recipient Sex of care recipient Male Female Education of care recipient Education of caregiver Number of ADLs Number of IADLs Self-rated health score Pseudo R2

B

SE

OR

p

.185 .016

.050 .008

1.203 .984

.000 .037

 .286 .049 .010 .061 .050 .214 .069

 .142 .021 .023 .039 .033 .081

 1.331 .952 .990 1.063 .951 .807

 .045 .016 .670 .122 .133 .008

satisfaction and depressive symptoms) mediated the relationship between impairment and depression among stroke survivors using data from the ongoing reasons for geographic and racial differences in stroke (REGARDS) study. Internationally, Huang, Lee, Liao, Wang, and Lai, (2012) found an association with caregiver burden and the psychological and behavior symptoms of dementia in a sample of Taiwanese elderly. Thus, studying the relationship between caregiver characteristics and care receiver mental health is still a viable area of research. Another limitation is that only one wave of data was used. A cross-sectional sample makes it difficult to distinguish which intervening pathways are more correct (Stage, Carter, & Nora, 2004). To establish a causal relationship between the effects of the mental health of a caregiver on the depressive symptomatology of the care receiver, at least two waves of data must be used. However, the questions asked in each wave of the NTLCS are not identical. Thus, we could not compare data across waves, and therefore, decided to use the most recent wave of the NLTCS. It can be argued that using a single item to measure emotional stress as in the NLTCS is an imprecise method (Diener, 1984). However, there is research that contends the usefulness and reliability of single-item measures, such as life satisfaction and self-rated health, in social and behavioral research (Dollinger & Malmquist, 2009; Jylh€a, 2009). Furthermore, depression in this study was dichotomized. Ideally, a scale measure of depression such as the 20-item CES-D or the DSM-IV-R should have been used to measure depressive symptomatology. However, depression in the NLTCS was measured by three questions. Furthermore, the majority of the sample (74.6%) had no depressive symptoms. Additionally, this study requires better measures of social resources. The RAND Social Health Battery used in this study only measures frequency of social contact with family and friends, and does not measure whether these ties are positive or negative. Civic organization participation also was not a good social resource measure for this group because the vast majority of respondents had not recently participated in civic organizations. A more

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appropriate measure of social connectedness is required for this group, such as the 20-item revised Social Connectedness Scale (Lee, Draper, & Lee, 2001). There was also an issue with the way caregiver age was measured. Primary caregiver age was not asked as a single question. Care receivers reported the age of all their caregivers together (each respondent could have up to 20 caregivers), thus age of primary caregiver could not be determined. Finally in the NLTCS, race and ethnicity are categorized in a complex way, with several different questions; thus, a respondent could report being of multiple races and ethnicities. Instead, we categorized race as black and non-black, following the categorization that the creator of this data-set used in his own work (Manton & Gu, 2001). Although it does not allow for rich comparison, it was the best way to represent race in this study. Furthermore, we ran multiple regression models with the more complicated measures of race and ethnicity, and race was not a significant covariate in any of the models; thus we decided to go with less complicated categorization. Conclusion The purpose of this study was to systematically evaluate the emotional stress of a primary caregiver as a possible stressor that results in adverse mental health in the aging population. This was to be done by conducting multivariate analyses of the correlation of caregiver depression with care recipient depression in the presence of mediating social and psychological resources using the NLTCS. Overall, the results supported the hypothesis that an emotionally stressed caregiver will be negatively associated with the mental health of a disabled care receiver. Even when health and social and psychological resources were taken into account, the emotional stress of a caregiver retained a very significant relationship with the depressive symptomatology of a disabled care receiver. This research sets the groundwork for further research. First of all, longitudinal analysis of the research question is required to establish a causal relationship between caregiver emotional stress and care receiver depressive symptomatology. Furthermore, there needs to be more work done to determine more appropriate social and psychological mediators for this study’s special population. Finally, this research emphasizes the importance of interventions, such as support groups, geared at caregivers to help improve their mental health and coping mechanisms. In addition, there is also a need for interventions targeted at caregivercare receiver dyads as a method of preventing adverse mental health conditions that result from caregiving. These interventions should focus on improving joint problem-solving skills and communication between the caregiver and the care receiver. This research has great importance in terms of its future implications for the field. To our knowledge, there has been no other research that has looked at caregiver emotional stress as a potential cause of depression for the care receiver. Understanding ‘the care receiver’s side’ could give us further insight in the delicate intricacies of elderly depression. By answering this research question, we have

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the potential to make great strides in depression care and management, and can improve the quality of life for millions of elderly individuals who suffer from this condition. Note 1.

In the NTLCS, age was collected for all eligible caregivers (both part-time and primary) in one question which asked the respondent to provide the ages of all their caregivers. Thus, the age of the primary caregiver could not be determined and was not included in this analysis.

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The effects of caregiver emotional stress on the depressive symptomatology of the care recipient.

Depression is a leading mental health issue affecting elderly individuals worldwide. Previous research widely neglects caregiver emotional stress as a...
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