To the best of our knowledge, this is the first study to systematically examine the association between mental resources (self-efficacy, sense of coherence, and social support), depressive symptoms, and mental health problems in formal and informal caregivers. We have found that personal resources are significant predictors of depressive symptoms and mental health outcomes in both groups of carers.
The purpose of this research was to understand how psychosocial factors modify the mental health of carers of people with Alzheimer's disease. This paper is based on theoretical background and empirical research on the psychosocial functioning of caregivers. We provide a description of caregivers’ mental health, expressed by the level of depression and assessment of their general health. Our results present certain predictors of mental health in carers of AD patients.
As stated in the introduction, the role of a carer of an AD patient is a difficult task, often extending beyond one’s adaptive capabilities, and is frequently associated with experiencing chronic stress [29]. Many studies suggest the existence of links between the severity of the disease and negative changes in the psychosomatic health of the carers, as well as increased morbidity and mortality [5,30].
Predictors of depressive symptoms
Our results indicate that a poor sense of comprehensibility is an important predictor of depression in formal and informal carers. As a component of the sense of coherence, this variable is associated with the perception of both external and internal stimuli as coherent and understandable [17]. A low sense of comprehensibility may result in a belief that the caregiver’s role is complicated, chaotic, inexplicable, or difficult to sort out. Hence, they may find it difficult to organize, explain, and find meaning in their situation [31].
A strong sense of comprehensibility, on the other hand, correlates with absence of depressive symptoms. It enhances the adaptation of personal resources to external contextual requirements, promoting a proactive attitude towards encountered difficulties. Such findings are consistent with the available research, which shows that the important predictors of depression in carers of people with Alzheimer's disease are factors related to caregiver characteristics and psychological situation, including their ability to cope with stress, sense of coherence, social support, personality, and the ages and financial status of the caregiver and care-recipient [32]. Studies also suggest that caregivers with a lower sense of coherence are at a higher risk of experiencing an increased burden of care as well as developing both physical and mental health problems [33].
Our research also indicates the importance of emotional support in the group of formal carers. Availability of supportive emotional behaviors - associated with a sense of acceptance from others and the ability to share feelings, care, and compassion - can reduce depressive symptoms. Such results are in line with research indicating the key role of social, family, and institutional support in reducing perceived burden of care [34]. However, in this study, the relationship between emotional support and depression was only significant in the group of formal caregivers. This suggests that emotional support may be a stronger predictor of depressive symptoms among those who perform the caregiver role as part of their professional work. In part, this may result from a greater need for acceptance, understanding, and compassion among formal carers who do not receive compensation for the burden of care they bear as part of their relationship with the care recipient. Nevertheless, the correlation observed in this study requires further investigation.
Predictors of mental health problems
Our research indicates that the most significant predictor of mental health in the group of informal carers is self-efficacy. Stronger self-efficacy favors greater motivation and commitment to attaining goals, even in situations that pose a major challenge to the individual. It is also conducive to involvement in health-related activities, active coping with stress, overcoming obstacles, and focusing on opportunities [35]. Low self-efficacy increases the risk of anxiety, depression, or feelings of helplessness, which can lead to a deterioration in psychosomatic health [36]. Our findings suggest that the belief that one's own actions are ineffective may be associated with a stronger subjective experience of stress and lower tolerance of stress. Care for close relatives involves emotional relations, which may increase the sense of control over external events and the sense of responsibility. A perceived inability to cope with difficulties results in a surge in stress levels, which affects activation of the autoimmune system, leading to immune deficiency. Development of a strong sense of self-efficacy may have an immunoenhancing effect [37]. Therefore, it seems important not only to have specific psychological resources, but also to perceive one’s own capabilities as sufficient to perform the caregiver role.
In the group of formal carers, the sense of meaningfulness was the strongest predictor of mental health. The higher its level, the better the carers’ perception of their mental health. Sense of meaningfulness is the most important emotional-motivational component of sense of coherence [38]. A strong sense of meaningfulness may be associated with the belief that fulfilling the role of carer is really worthwhile and that there is good reason to commit to it. Formal carers can be protected from burnout syndrome by encouraging them to consider their work a challenge, building greater involvement, and finding meaning in their actions. In the face of difficult events, people with a strong sense of meaningfulness can better understand the situation they are in, are more aware of available coping strategies, and are more motivated to overcome difficulties [31]. Studies on persons with somatic illness indicate that sense of coherence is a strong determinant of positive health outcomes and successful coping [24]. The sense of meaning plays a major role here, reinforcing the other two elements [17], and constituting an important resource for maintaining proper health levels [38].
The results of our analyses also indicate the importance of tangible support in the group of formal carers. A perceived availability of help in dealing with problems at work and relief from excessive duties can lead to a better assessment of health. Various studies suggest that support can reduce negative health outcomes resulting from performing a caregiver role [39,40]. Working with the elderly can be a great burden, which can lead to burnout. The burden is related to, inter alia, the patient-caregiver relationship that is created during the provision of care. Caregivers who maintain better relationships with patients are more effective in their work [41]. In turn, caring for a patient with no emotional attachment can lead to excessive criticism, anger, and hostility. Absence of sufficient support, social isolation, and stigmatization tend to result in an elevated sense of burden and greater feelings of loneliness. All this may lead to a decreased quality of life [42].
Comprehensive research into the relationship between personal resources and caregivers' health, with a particular focus on the differences between formal and informal care, can help assess relevant risk factors. The statistical analyses performed showed no significant differences in the levels of personal resources, depressive symptoms, or mental health of carers from the two groups examined, which may be an important step for further analysis of problems in psychosocial functioning, especially in the population of formal carers. It seems particularly important to provide emotional and psychological support to caregivers to prevent professional burnout as well as to include caregivers who are at the very start of their careers. There are several limitations when interpreting the results of this study. Cross-sectional analyses preclude the determination of causal associations. Increasing the sample size would allow for more advanced analyses that could demonstrate other types of dependencies. It seems important to focus on the needs of caregivers and the possibility of introducing preventive measures aimed at building personal resources, which could foster better coping with the burden of care. We were also limited by the base study measures. The GHQ is a screening tool that does not allow clinical assessment of mental health. Another important limitation was the lack of a stress assessment tool. Nevertheless, this study provides the foundation for subsequent work to elucidate knowledge of the proliferation of caregiving stress among aging adults caring for relations with functional disability.
Directions for future research
Formal carers are a group whose role is to support family carers, supplement care services, and sometimes take over care functions. The daily care of a patient is a source of chronic stress, which can lead to numerous negative outcomes, including negative assessment of one's own life, emotional distance from the care recipient, neglect, hostility, and indifference to their needs. Fatigue, resulting from too many duties, significantly contributes to the deterioration of psychosomatic health [43]. In this study, there were no statistically significant differences between formal and informal carers in the assessment of mental health, which suggests that significant problems are not limited to family carers only. However, effective action can only be initiated once the problem has been examined in greater detail. This study may thus become the foundation for introducing systematic research, allowing the assessment of factors affecting the mental health of formal and informal carers and providing such carers with adequate support. Organization of caregiver support groups seems to be of particular importance. The use of appropriate psychotherapeutic interventions can improve the psychosomatic health of caregivers.
An increase in self-efficacy can affect an individual's physiology, contributing to improved health outcomes and sense of well-being. The inclusion of caregivers in a social support network helps them increase their self-esteem, gives a sense of greater opportunities, and fosters positive feelings, thus constituting a protective factor against the development of somatic diseases [44]. Analysis of empirical research by [45] indicates the mediation of the sense of coherence in explaining health. Researchers suggest a positive relationship between the sense of coherence and subjective health assessment [46], and better mental and physical health [47]. Predictors of mental health presented in this paper contribute to the current picture of the problem. Strengthening caregivers’ personal resources can reduce the likelihood of their manifesting non-adaptive behaviors. The proposed model of mental health promotion in caregivers of AD patients is the starting point for more systematic research, the results of which could help refine the model. It is also worth considering the role of other factors that are important for the mental health of carers, such as personality, stress levels, lifestyle, and cognitive functioning.