The study sought to explain the relationship between care burden and depressive symptoms based on Kumpfer's resilience model. Firstly, our findings showed that the mean score of depressive symptoms value was 22.33±9.85, which was higher compared with the level of care burden reported in a study using the same tool among caregivers of patients with other diseases[35, 36]. The difference might be since a long disease duration and residual disability among stroke patients are likely more reliant on their family caregivers.
In our sample of caregivers, depressive symptoms were related to patients, side of hemiplegia, BDLAI and caregivers' education status, monthly income, working status, relationship with patients, care time per day, and living with patients. Patients with hemiplegia are associated with self-care abilities, which inevitably disrupt the normal life of the caregivers and further develop negative emotions. Similar to the previous study, we found that caregivers with a higher level of education tend to experience fewer depressive symptoms, which may be due to better ways to insight into illness and seek help, resulting in lesser depression. Unemployed people and lower-income families experience more depressive symptoms. It is well known that limited economic resources increase the burden of maintaining daily life and paying for health services. In addition, family caregivers who spent a long time on caregiving were associated with higher depression. It was assumed that the longer time spent, the more disruptions they experience in their normal social routines, which in turn causes more stress. In our study, there was a trend that the levels of depression declined, starting from parents, spouses, and moving on to offspring, siblings. Perhaps because those parents are disposed to make sacrifices in taking care of children, making them especially susceptible. Another reason may be that older people are more vulnerable to most kinds of chronic diseases. Contrary to this finding, some studies stated that spouses reported more depressive symptoms[42, 43], which may be because those spouses are overwhelmed by conflicting demands such as work, children, and household chores. Thus, early and ongoing assessment of influencing factors mentioned above for caregivers could be helpful to meet caregivers’ mental health needs.
Our findings demonstrate that the care burden had a direct effect on the depressive symptoms of main family caregivers. The direct effect can be explained by the features of the stroke itself. Specifically, due to the chronicity of stroke and the loss of limb function, family caregivers get insufficient time for sleep, socialization, and mental relaxation, sometimes feel desperate and hopeless when caring for a relative living with stroke, which inevitably develops negative emotion and further suffers from depression. Hence the more care burden, the heavier depressive symptoms family caregivers may perceive. Also, our findings showed that the mean score of care burden value was 43.89±13.40, which was significantly higher than that of caregivers of patients with other diseases[45, 46]. The difference might be since that chronic course of and having some residual symptoms among stroke patients has a greater burden on caregivers.
Notably, our results showed that resilience could partly mediate the relationship between care burden and depressive symptoms. One possible explanation may be that people with a lower level of resilience tend to negatively confront adversity in unhealthy ways, such as mood disturbances, persisting fatigue, sleep changes. Specifically, the psychobiological mechanisms underlying resilience has shown that resilience had a relation to neurochemical, neuropeptide, and hormonal when the response to stressful things[49, 50], people with higher resilience tend to reduce psychobiological allostatic load, balance neural systems, which could maintain normal psychological function and thus can confront stress actively. Besides, individuals with higher resilience are better at coping with stressful events, they tend to make active attempts to adjust the relationship between the environment and individuals, make full use of various resources, and achieve a good state of adaptation[52, 53]. Therefore, resilience seemed to be one of the possible mechanisms to resist mental disorders who exposure to care burden, which confirmed Kumpfer's resilience model. Resilience is a dynamic phenomenon that can be altered at any moment. Hence, it is possible to alleviate the depressive symptoms of caregivers via promoting the level of resilience. Specifically, social support is one of the important sources for the development of resilience, which may ultimately help lessen depressive symptoms. Self-compassion and mindfulness training are also related to higher resilience. Moreover, some research has shown that love for family, feeling responsible toward the family, ability to analyze the current situation, and capability to establish relationships are some of the motivations for resilience. Similarly, care burden is related to mental health. We should assess the situation of care burden of caregivers, screen for its main influencing factors, and take effective programs such as social and financial support, increased post-traumatic, better patient-caregiver relationships, growth improvement in the competence and self-esteem of caregivers. Overall, the sources of strength can provide intervention targets for promoting resilience and care burden, and thus alleviate the depressive symptoms .
Limitations and future research
This study had several potential limitations. First, this study is a cross-sectional study, and it is difficult to determine the causal connections between the variables. Therefore, future studies can use longitudinal research to explore the causal relationship between variables. Second, we used a self-rating questionnaire for screening depression instead of a clinical diagnosis from psychiatrists. Irrespective, the instrument is a validated depression screening tool. Finally, our study focused only on the association between care burden, resilience, and depression. Further investigation needs to be taken into consideration to explore other social psychology and emotional predictors for the level of depression in caregivers of stroke survivors, such as society, family environment factors, and so on.