Psychiatry Research 200 (2012) 896903

Contents lists available at SciVerse ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Validity and reliability of the Spanish version of the Involvement Evaluation

Questionnaire among caregivers of patients with eating disorders
Nerea Gonzalez a,n, Amaia Bilbao b, Angel Padierna c, Josune Martn a, Miren Orive a, Jose M Quintana a,d
a o
CIBER of Epidemiology and Public Health, Research Unit, Hospital Galdakao-UsansoloCIBERESP, B % Labeaga, s/n. 48960 Galdakao, Bizkaia, Spain
b
Research Unit, Hospital Universitario BasurtoCIBERESP, Bilbao, Bizkaia, Spain
c
Psychiatry Service, Hospital Galdakao-UsansoloCIBERESP, Galdakao, Bizkaia, Spain
d
Preventive Medicine and Public Health Department, University of the Basque Country, Leioa, Bizkaia, Spain

a r t i c l e i n f o a b s t r a c t

Article history: The Involvement Evaluation Questionnaire (IEQ) was developed to evaluate burden among caregivers
Received 2 March 2012 of patients with schizophrenia. We aimed to examine its psychometric properties among caregivers of
Received in revised form patients with eating disorders (ED). A prospective study was carried out, recruiting caregivers of
13 July 2012
patients with an ED attending two outpatient clinics in Bizkaia, Spain. Caregivers provided socio-
Accepted 23 July 2012
demographic information and completed the Involvement Evaluation Questionnaire (IEQ), the Hospital
Anxiety and Depression Scale (HADS), the Short-Form 12 (SF-12) and the Anorectic Behaviour
Keywords: Observation Scale (ABOS). The same information was requested one year later. The conrmatory factor
Caregiver analysis (CFA) provided satisfactory t indexes. Almost all of the factor loadings were above 0.40.
Burden
Cronbachs alpha coefcients were mostly superior to 0.70. The correlation coefcients between the IEQ
Consequences
domains and the other questionnaires were lower than the Cronbachs alpha coefcients. Known-
Psychometric properties
groups validity was supported by signicant differences in the IEQ mean scores according to certain
variables, as contact hours, living with the patient, type of caregiver and gender. The indexes employed
for the evaluation of responsiveness were between 0.13 and 0.99. The IEQ has good psychometric
properties and can be used to evaluate burden among caregivers of patients with ED.
& 2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Several instruments have been developed to evaluate caregiver

Caring for a family member or other relative with a chronic
disorder can be a stressful endeavour associated with anxiety,
depression, and physical discomfort, not to mention continuing
concern for the health status of the aficted family member or
relative (Treasure, 2004; Hirst, 2005). This stress has been called
caregiver burden. Platt (1985), one of the rst to investigate this
problem, dened caregiver burden as problems, difculties or
adverse events that affect the lives of a patients signicant
others (Platt, 1985). Other authors, as Lazarus and Folkman
(1984), have emphasised that the reaction to the stress the
caregiving causes is in some way mitigated by the ability of the
carer to perceive the situation as threatening or not. Whereas
Platt (1985) deals with the experience of caregiving as something
essentially negative, Lazarus and Folkman (1984) consider differ-
ences depending on the way the carer faces and evaluates the
situation; those caregivers who perceive the caregiving experi-
ence as positive, would perceive less burden.
n
Corresponding author. Tel.: 34 94007105; fax: 34 944007132.
E-mail address: nerea.gonzalezhernandez@osakidetza.net (N. Gonzalez).
burden in different disorders (Vitaliano et al., 1991; Schene et al.,
1994; Kinsella et al., 1998; Deeken et al., 2003; Haigh and
Treasure, 2003; Visser-Meily et al., 2004; Sepulveda et al., 2008;
Sepulveda et al., 2009; Whalen and Buchholz, 2009).One such
instrument is the Involvement Evaluation Questionnaire (IEQ)
(Schene and van Wijngaarden, 1992). The IEQ was initially
developed to measure the perception and consequences of care-
giver burden among carers of patients with psychotic disorders
(Schene and van Wijngaarden, 1992; Van Wijngaarden et al.,
1996) where it showed a good reliability and validity, in terms of
content and construct validity. The IEQ was translated into
Spanish and validated in Spain in this population (van
Wijngaarden et al., 2000), but these authors have only published
the reliability data of this version, with good results for the
internal consistency and the testretest reliability. Recently, this
questionnaire has been validated in caregivers of brain injured
patients, showing also good data on reliability and validity, and
moderate for responsiveness (Geurtsen et al., 2010). In both cases,
the number of factors was the same as in the original version of
the questionnaire.
The IEQ has also been used among caregivers of patients with
affective disorders (van Wijngaarden et al., 2004; Cleary et al.,

0165-1781/$ - see front matter & 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.psychres.2012.07.033
 N. Gonzalez et al. / Psychiatry Research 200 (2012) 896903
2006; van Wijngaarden et al., 2009) and eating disorders (ED)
(Martn et al., 2011; Padierna et al., in press), but it has not yet
been validated in the latter population, so our hypothesis was
that this questionnaire could also show good psychometric
properties for carers of patients with ED.
The primary aim of our study was to evaluate several psycho-
metric properties of the IEQ in a sample of caregivers of patients
with EDs: (a) internal consistency reliability (Cronbachs alpha,
and intercorrelations between scales); (b) construct validity
(conrmatory factor analysis (CFA), convergent and discriminant
validity), and (c) responsiveness.
2. Method
2.1. Subjects
This prospective study recruited caregivers of patients attending the Eating
Disorders Outpatient Clinic of the Psychiatric Services at Galdakao-Usansolo
Hospital and Ortuella Mental Health Center in Bizkaia, Spain. Both are part of
the network of public health-care centres of the Basque Health Service, which
provides unlimited free care to nearly 100% of the population.
Caregivers were considered for inclusion if they were a primary caregiver for
an outpatient diagnosed with an ED, obtained consent to participate in the study
from the patient for whom they were caring, and provided written informed
consent to participate. According to criteria established by Perlick et al. (2005), a
primary caregiver is dened as a person who fulls three or more of the following
criteria: (1) is the patients parent, partner, or other relative; (2) maintains
frequent contact with the patient; (3) provides signicant nancial support to
the patient; (4) is the person most often present with the patient during
consultation or treatment and who is aware of the severity of the illness
(accompanies the patient to medical appointments, participates in consultations
and therapy, supervises eating behaviour at home, etc.); and (5) is one of the
individuals the therapy team should contact in the event of an emergency. As part
of our units standard protocol, all ED caregivers receive professional counselling
from clinicians to deal with their relatives ED. Caregivers were excluded if they
had a malignant, severe organic disease, could not complete the questionnaires
due to language barriers, or did not give written informed consent.
The institutional review board of Galdakao-Usansolo Hospital approved this
project.
2.2. Materials
Each caregiver was asked to provide sociodemographic information, including
age, gender, marital status, level of education, relationship with the patient,
whether he or she lived with the patient, and number of contact hours per week
he or she had with the patient (o 32 or Z32 h). Caregivers were also asked to
complete four questionnaires.
The Involvement Evaluation QuestionnaireEU Version (IEQ-EU) (Schene and
Wijngaarden, 1992; Van Wijngaarden et al., 1996; van Wijngaarden et al., 2000)
measures the psychosocial burden of caregiving. This self-reported questionnaire
is scored on a ve-point Likert scale. It can be summarised into four distinct
domains: Tension (9 items; score range from 0 to 36), which refers to strains in the
interpersonal atmosphere between the patient and the caregiver; Supervision
(6 items; score range from 0 to 24), which evaluates the caregivers task of
guarding the patient; Worrying (6 items; score range from 0 to 24), which covers
the caregivers concerns about the patients safety, future, and health; and Urging
(8 items; score range from 0 to 32), which assesses the caregivers need to prompt
or encourage the patient to undertake activities. Two items load on two subscales.
A total score for the 27 items can be calculated by summing the answers to all of
the items, with higher score indicating a higher burden perception (score range
from 0 to 108). This questionnaire has been translated into Spanish and validated
in Spain among caregivers of patients with schizophrenia (van Wijngaarden et al.,
2000), where it showed good internal consistency and adequate testretest
reliability. Cronbachs alpha coefcients of this Spanish version were between
0.68 and 0.87.
The Hospital Anxiety and Depression Scale (HADS) was designed to measure
anxiety and depression in nonpsychiatric settings (Zigmond and Snaith, 1983). It
includes 14 items7 for evaluating anxiety and 7 for depression. All items are
presented in a Likert format with four possible responses ranging from 0 to 3.
Thus, the possible score ranges from 0 to 21 for both the anxiety and depression
subscales. A score of 07 on a subscale is considered normal (indicating the
absence of anxiety or depression); a score of 8, 9, or 10 indicates a possible case of
anxiety or depression; and a score of 11 or higher indicates the presence of anxiety
or depression (Zigmond and Snaith, 1983). The validity and reliability of the HADS
have been conrmed (Herrmann, 1997), and it has been adapted and validated in a
897
Spanish population (Quintana et al., 2003), with Cronbachs alpha coefcients of
0.86 both for anxiety and depression.
The Short-Form 12 (SF-12) (Ware et al., 1996) is a 12-item instrument designed
to measure general health-related quality of life (HRQoL). Answers provide two
summary scores, the mental component scale (MCS) and physical component
scale (PCS), which reect the individuals perceived mental and physical health.
Scores range from 0 to 100 on each subscale. The higher the score, the more
positive the perception of health. We used a version of the SF-12 validated in
Spanish (Gandek et al., 1998; Vilagut et al., 2008) and its Cronbachs alpha
coefcients were 0.85 for the physical component scale and 0.78 for the mental
component scale.
The Anorectic Behaviour Observation Scale (ABOS) (Vandereycken, 1992) is used to
evaluate a patients eating behaviour based on information provided by his or her
caregiver. The ABOS consists of 30 items in three domains: factor Ieating behaviour,
concern with weight and foods, and denial of problems; factor IIbulimic-like
behaviour; and factor IIIhyperactivity. Questions are to be answered yes (2 points)
or no (0 points) if the person is certain of the answer, and ? (1 point) if he or she is
uncertain about it. Scores range from 0 to 60; the higher the score, the greater the
patients pathology. The authors of the original version proposed that a score of 19 or
higher identied a patient with an ED (Vandereycken, 1992). This questionnaire has
been translated into Spanish (Instituto Nacional de la Salud, 1995).
2.3. Procedure
Data collection started in 2007; one-year follow-ups were conducted through
2008. Psychiatrists collaborating in the study informed their patients about the
objectives of the study and requested the participation of their primary caregivers.
Those who agreed to take part in the study received the questionnaires and the
informed consent form by mail. They were asked to return these by mail using an
enclosed, pre-stamped envelope. Caregivers who did not return the information
within 20 days were sent a reminder letter.
The same documents were mailed to participants one year after the rst round
of information gathering. As before, those who did not return the information
within 20 days were sent a reminder letter.
2.4. Statistical analysis
The statistical description of the sample was done using means and standard
deviations (S.D.s), frequencies, and percentages.
The construct validity of the IEQ was evaluated by means of a conrmatory
factor analysis (CFA) for categorical variables to conrm the hypothesis that the 27
items on the questionnaire did, indeed, comprise four factors as proposed by the
original authors (Schene and Wijngaarden, 1992; van Wijngaarden et al., 2000).
Four indexes of t were evaluated (Mulaik, 1989; Hatcher, 1994; Devins et al.,
2001; Batista-Foguet et al., 2004): (a) w2 test divided by the degrees of freedom,
the result of which had to be r 2 to be acceptable; (b) the root mean squared error
of approximation (RMSEA), where a value o0.08 was considered acceptable;
(c) the comparative t index (CFI) and (d) the TuckerLewis Index (TLI), both of
which had to be 40.90 to be satisfactory. Factor loadings were also examined, and
those Z 0.40 were considered acceptable. The model was considered acceptable if
it surpassed these criteria.
Reliability was assessed with Cronbachs alpha coefcient (Cronbach, 1951). A
coefcient 40.70 was considered acceptable (Nunnally and Bernstein, 1994).
The convergent and discriminant validity of the IEQ domains were explored by
their correlations with each other, as well as with the SF-12, HADS and ABOS
domains. We established that correlations between the IEQ domains and the other
measures must be lower than the internal consistency of the IEQ scales, as
measured by Cronbachs alpha (Fayers and Machin, 2000). We expected that the
IEQ domains would correlate more strongly with each other, then with the HADS
and the ABOS, and lowest with the SF-12. The Spearman correlation coefcient
was used.
For known-groups validity, we expected that the IEQ would capture the
difference between caregivers divided by different criteria: (a) weekly contact
hours with the patient, (b) living with the patient, (c) gender, and (d) type of
caregiver. Following the results found in other studies (Schene et al., 1998; Lowyck
et al., 2004; Gutierrez-Maldonado et al., 2005; Roick et al., 2006) and the
experience of the clinicians of our team, we hypothesised that the IEQ scores
would be higher (greater perception of caregiver burden) for caregivers with more
contact hours, those who lived with the patient, women, and mothers, or partners.
Therefore, the IEQ mean scores were compared among the different subgroups by
the t-test or the analysis of variance (ANOVA) with Scheffe test for multiple
comparisons, or the non-parametric Wilcoxon test or KruskalWallis test if the
assumption of normality was not met.
We compared principal characteristics between caregivers who responded to
the follow-up and those who did not. We used the w2 test or the Fisher exact test
for the comparison of categorical variables, and the t-test or the non-parametric
Wilcoxon test for the comparison of quantitative variables. Means and S.D.s were
calculated for the IEQ domains at baseline and at one-year follow-up, and a paired
t-test was used for the comparison of scores at those two time points. Ceiling and
898 N. Gonzalez et al. / Psychiatry Research 200 (2012) 896903
oor effects at baseline and at one-year follow-up were examined to evaluate the
discriminatory ability of the scales. To measure the responsiveness of the IEQ
domains, we used the standardised effect size (SES), dened as the mean change
score divided by the S.D. of the baseline scores, and the standardised response
mean (SRM), dened as the mean change score divided by the S.D. of the change
scores (Guillemin et al., 1993). Cohens benchmarks were used to classify the
magnitude of the effect sizes (Cohen, 1992): not signicant, below 0.20; small,
between 0.20 and 0.50; moderate, between 0.50 and 0.80; and large, above 0.80.
Having in mind that anxiety was one of the main variables with inuence in the
change in burden perception (Gonzalez et al., 2012), we decided to perform the
responsiveness study separately according to groups dened by the HADS anxiety
scale as follows: those patients with baseline score 410 and follow-up score r 10
were classied as improved; those with baseline score r10 and follow-up score
410 were considered worsened; and those with baseline and follow-up scores
r 10 or with baseline and follow-up scores 410 were classied as equal. We
hypothesised that both SES and SRM results would be higher among improved
patients than among patients classied as unchanged.
Effects were considered signicant at po 0.05. All statistical analyses were
performed with SAS for Windows statistical software, version 9.2 (SAS Institute,
Inc., Cary, NC), except the conrmatory factor analysis for categorical variables, for
which we used Mplus version 6.1 software (Muthen and Muthen, 1998, Los
Angeles).
3. Results
The sample included 309 caregivers, 246 of whom completed
the questionnaires at baseline (79.6%), and 143 did it also at the
follow-up (58.1%). The dropouts at the beginning of the study
were caused mainly because patients did not gave their consent
to their carers to participate, and in the follow-up because the
difculties to locate the caregivers due to changes in their
addresses or telephones, or because the caregivers did not want
to continue participating in the study.
The basic descriptive information of the sample is presented in
Table 1. More than half (53.25%) of the caregivers were women
and 51.63% were between 46 and 60 years. The majority (85.66%)
of the caregivers lived with the patient, and 55% spent less than
32 h per week with the patient. Means for the IEQ subscales were
7.39 for tension, 2.37 for supervision, 12.23 for worrying, 6.75 for
urging and 26.64 for the total subscale. In the patient sample, the
majority were women (98.6%), with a mean age of 25.73. Three
main diagnoses were detected, 44.14% of the patients having
anorexia nervosa, 24.83% had bulimia nervosa and 31.03% had an
EDNOS. The clinician evaluated that the illness was severe in
37.93% of the patients. And, nally, the 56.25% of the patients
begun with the disorder more than 5 years ago.
3.1. Construct validity: conrmatory factor analysis
The results of the CFA provided satisfactory t indexes
(Table 2). w2 divided by the degrees of freedom was 1.86, less
than the benchmark of 2. The RMSEA values were less than 0.08,
while CFI and TLI both exceeded the benchmark of 0.90. All factor
loadings were statistically signicant (p o0.05) and almost all of
the factor loadings were above the criteria of 0.40 (range 0.22
0.90), which supported the stability of the structure of this
questionnaire in this sample. Although Items 15 (Encouraged to
eat enough) and 41 (Worried about ones own future) did not
reach the minimum factor loading required, both were higher
than 0.30 (0.33 and 0.36, respectively). The lowest factor loading
was found with item 20 (Ensuring that patients take the required
medicine), which had a factor loading of 0.25. Items 28 and 42,
which the authors of the original version assigned each to two
different factors, clearly loaded in one of them: item 28
(Disturbed carers sleep) in the supervision domain and item
42 (Global burden) in the tension domain.
3.2. Reliability
Four of the IEQ domains exceeded the minimum Cronbachs
alpha coefcient of 0.70: tension (0.76), supervision (0.80),
worrying (0.81) and total (0.84). Urging (0.66) did not.
3.3. Convergent and discriminant validity
Correlation coefcients between the IEQ domains and the other
questionnaires (HADS, ABOS, and SF-12) were all lower than the
Cronbachs alpha coefcients of the IEQ subscales (Table 3).
As expected, the highest correlations were between the
tension and worrying domains of the IEQ, with a correlation
coefcient of 0.57.The IEQ subscales correlated higher with the
HAD and the ABOS questionnaires (r between 0.52 and 0.06)
and lower with the SF-12 (r between  0.40 and  0.07).
3.4. Known-groups validity
The differences in the mean IEQ scores were statistically
signicant according to the variables used to evaluate known-
groups validity. As hypothesised, greater burden perceptions
were observed in the total score and the urging domain for
caregivers with 32 or more hours of contact per week with the
ED patient (p 0.003); in the tension domain for those living with
the patient (p 0.004), in supervision for caregivers who were the
patients partner (p 0.003) and for females (p 0.42); and in the
worrying domain for mothers (p0.033) and females (p 0.008).
The global burden perception measured by the total score
obtained statistically signicant differences in all the variables,
except living with the patient (Table 4).
3.5. Responsiveness
Signicant differences were observed in anxiety and depres-
sion between caregivers who completed the questionnaires at the
beginning of the study and after one year of follow-up and those
who did not complete the questionnaires at the one-year follow-
up (Table 1). Mean HADS anxiety scores were 8.75 74.30 in one-
year respondents vs 6.83 74.27 in nonrespondents; mean depres-
sion scores were 6.0574.05 in one-year respondents vs
4.5573.66 in nonrespondents. Differences were also observed
in the MCS of the SF-12, with mean scores of 42.41 710.52 in
one-year respondents and 46.7279.69 in nonrespondents. No
statistically signicant differences were observed in IEQ scales.
Both ceiling and oor effects of the four domains were generally
low, except for supervision, which showed high oor effects at
baseline (37.14%) and follow-up (46.72%). The responsiveness
information is presented in Table 5, according to groups dened
by baseline and follow-up HADS anxiety scale, in order to
evaluate if the questionnaire detects a change when another
instrument does. Since the sample size in the worsened group
was too small, the responsiveness study was not performed in
this group. After one year of follow-up, in the unchanged group
mean scores on the IEQ scales decreased signicantly in the
tension (1.16 points), worrying (2.63 points), urging domains
(1.24 points), and the total score (4.86), but not in the supervision
domain (0.48 points; p 0.054). These changes were higher in
those patients who improved in anxiety, being the differences
statistically signicant in all the subscales. The SES and SRM
indexes of the IEQ were between 0.10 and 0.52 for the unchanged
group, and between 0.38 and 0.99 for the improved group.
 N. Gonzalez et al. / Psychiatry Research 200 (2012) 896903 899

Table 1
Descriptive data.

Respondents at baseline Respondents at follow-up Non-respondents at follow-up p value

(n 246) (n 143) (n 103)

Gendera (female) 131 (53.25) 78 (54.55) 53 (45.45) 0.698

Agea 0.088
r45 82 (33.33) 40 (27.97) 42 (40.78)
4660 127 (51.63) 78 (54.55) 49 (47.57)
460 37 (15.04) 25 (11.65) 12 (17.48)

Marital statusa 0.126

Single 33 (13.41) 13 (9.09) 20 (19.42)
Spouse/partner 191 (77.64) 117 (81.82) 74 (71.84)
Divorced 11 (4.47) 6 (4.20) 5 (4.85)
Widowed 11 (4.47) 7 (4.90) 4 (3.88)

Educational levela 0.958

No studies/primary education 100 (41.49) 60 (42.25) 40 (40.40)
Secondary education 53 (21.99) 31 (21.83) 22 (22.22)
University education 88 (36.51) 51 (35.92) 37 (37.37)

Relationship to the patienta 0.145

Mother 111 (45.12) 68 (47.55) 43 (41.75)
Father 70 (28.46) 45 (31.47) 25 (24.27)
Spouse/partner 34 (13.82) 16 (11.19) 18 (17.48)
Otherc 31 (12.60) 14 (9.79) 17 (16.50)

Living with patienta 0.713

Yes 209 (85.66) 122 (86.52) 87 (84.47)
No 35 (14.34) 19 (13.48) 16 (15.53)

Weekly contact hours with the patienta 0.149

o32 132 (55) 70 (50.72) 62 (60.78)
Z32 108 (45) 68 (49.28) 40 (39.22)

HADSb
Anxiety 7.94 (4.38) 8.75 (4.30) 6.83 (4.27) 0.001
Depression 5.42 (3.95) 6.05 (4.05) 4.55 (3.66) 0.003

ABOSb
Factor I 12.73 (6.43) 13.34 (6.26) 11.89 (6.60) 0.101
Factor II 4.86 (3.46) 5.04 (3.29) 4.61 (3.68) 0.179
Factor III 4.92 (3.44) 5.10 (3.34) 4.67 (3.57) 0.327
Total 22.51 (10.46) 23.52 (9.89) 21.08 (11.13) 0.071

SF-12b
MCS 44.23 (10.38) 42.41 (10.52) 46.72 (9.69) 0.002
PCS 52.05 (7.56) 51.64 (8.07) 52.62 (9.69) 0.497

IEQ-EU Scalesb
Tension 7.39 (4.77) 7.66 (4.73) 7.01 (4.82) 0.289
Supervision 2.37 (3.76) 2.31 (3.80) 2.47 (3.72) 0.850
Worrying 12.23 (5.87) 12.69 (5.87) 11.60 (5.83) 0.138
Urging 6.75 (4.44) 6.97 (4.44) 6.44 (4.44) 0.465
Total 26.64 (13.40) 27.38 (13.48) 25.60 (13.28) 0.391

SF-12 (PCS): Physical Component Score of the SF-12. SF-12 (MCS): Mental Component Score of the SF-12.
ABOS score ranges: Factor I (Eating behaviour, concern with weight and foods, denial of problems) 032; Factor II (Bulimic-like behaviour) 014; Factor III (Hyperactivity)
014; Total 032.
IEQ score ranges: Tension 036; Supervision 024; Worrying 024; Urging 032; Total 0108.
a
These variables are presented as frequencies and percentages.
b
These variables are presented as means and standard deviations.
c
Other: sibling or child of the ED patient.

4. Discussion subscales are measuring the same concept. Other reliability

The IEQ was originally created to evaluate the burden imposed
by providing care to a family member with a psychotic
or affective disorder (Schene and van Wijngaarden, 1992;
van Wijngaarden et al., 2004). To see if this instrument could be
used in other caregiver populations, we applied it to a sample of
individuals caring for patients with ED. Our results suggest that
the IEQ is a useful instrument for assessing caregiver burden in
this group.
The reliability estimates were high, in line with standard
criteria for reliability (Cronbach, 1951). They were also similar
to those of the original version of the IEQ (Van Wijngaarden et al.,
1996) and to the Spanish version (van Wijngaarden et al., 2000).
These data indicate that the items included in each of the
parameters of the IEQ could be evaluated in future studies in
carers of patients with ED to add further evidence of its quality.
The validity results were also good. The CFA results conrmed
the hypothesised internal structure of the four latent factors of
the original version of the IEQ (Schene et al., 1998) tension,
worrying, supervision, and urging given that the t indexes
were satisfactory and almost all factor loadings exceeded the
recommended criteria (Hatcher, 1994; Batista-Foguet et al.,
2004). Only two items, 15 (Encouraged to eat enough) and 20
(Ensured they take the required medicine), fell short of those
criteria. Item number 20 was initially included in the supervision
factor (Schene et al., 1998). In later papers, however, the authors
of the original version of the IEQ incorporated this item in the
urging factor (van Wijngaarden et al., 2000; Van Wijngaarden
900 N. Gonzalez et al. / Psychiatry Research 200 (2012) 896903

Table 2
Conrmatory factor analysis: factor loadings and t indexes (n 246).

Items Factor 1: Tension Factor 2: Supervision Factor 3: Worrying Factor 4: Urging

29: Strained atmosphere 0.89

30: Quarrels caused by patient 0.87
31: Carer annoyed by behaviour 0.90
32: Other annoyed by behaviour 0.44
33: Felt threatened by the patient 0.68
34: Considered moving out 0.63
41: Worried about ones own future 0.36
42: Global burden 0.43 0.28
21: Guarded from committing dangerous acts 0.82
22: Guarding from self-harm 0.86
23: Ensured sufcient sleep 0.64
24: Guarding from alcohol misuse 0.85
25: Guarding from taking illegal drugs 0.88
28: Disturbed carers sleep 0.22 0.57
36: Worried about patients safety 0.77
37: Worried about kind of treatment 0.78
38: Worried about patients general health 0.88
39: Worried about how they would manage nancially without your help 0.62
40: Worried about patients future 0.78
15: Encouraged to eat enough 0.33
16: Helped patient to take proper care of himself or herself 0.68
17: Urged patient to take proper care of himself or herself 0.70
18: Encouraged patient to undertake an activity 0.76
19: Accompanied patient on an outside activity 0.63
20: Ensured that patient take the required medicine 0.25
26: Carried out tasks normally done by the patient 0.60
27: Encouraged patient to get up in the morning 0.70
v2 (d.f.) 583.799 (314)
RMSEA (90% CI) 0.067 (0.0580.075)
Comparative t index 0.91
TLI 0.90

Factor 1: Tension. Factor 2: Supervision. Factor 3: Worrying. Factor 4: Urging.w2: Chi-square; d.f.: degrees of freedom.
RMSEA: root mean square error of approximation; CI: condence interval; TLI: TuckerLewis Index.
Correlation between the four latent factors is set to be different from 0, therefore four latent factors are specied to be intercorrelated. Covariance was specied between
the error items of the following two pair of items: Item 40 (Worried about patients future) and 41 (Worried about ones own future), and items 24 (Guarding from alcohol
misuse) and 33 (Felt threatened by the patient).

Table 3 structure that the authors of the IEQ used in their last reports,
Convergent and discriminant validity (n 246).
maintaining item 20 in the urging factor. In addition, items 28 and
IEQ scales
42, which in the original version contributed each to two different
factors, in our sample clearly loaded in one of them, suggesting
Tension Supervision Worrying Urging Total that item 28 (disturbed caregivers sleep) is better suited in the
supervision domain and item 42 (global burden) performs best in
IEQ
the tension domain.
Tension 0.76y
Supervision 0.39* 0.80 Convergent and discriminant validities were assessed by exam-
Worrying 0.57* 0.36* 0.81 ining the correlations of the IEQ domains with those of the HADS,
Urging 0.41* 0.44* 0.39* 0.66 ABOS, and SF-12. The correlation coefcients of the IEQ subscales
Total 0.76* 0.61* 0.83* 0.72* 0.84
with each other and with other questionnaires were all lower than
SF-12 the Cronbachs alpha coefcients, supporting the validity of the IEQ
MCS  0.40*  0.37*  0.28*  0.26*  0.40* for assessing caregiver burden among caregivers of patients with ED.
PCS  0.17*  0.10  0.23*  0.07  0.17*
It must be noted that although all the correlations were statistically
HADS signicant, almost all of them were weak. They were, however,
Anxiety 0.44* 0.30* 0.42* 0.34* 0.49*
similar to those shown in other studies using the IEQ (Parabiaghi
Depression 0.41* 0.30* 0.38* 0.23* 0.43*
et al., 2007; Goossens et al., 2008). Finally, we evaluated the known-
ABOSa group validity in order to estimate how well the IEQ discriminates
Total 0.51* 0.30* 0.39* 0.23* 0.47*
Factor I 0.52* 0.25* 0.36* 0.21* 0.44*
between groups. As other authors have observed (Schene et al.,
Factor II 0.31* 0.35* 0.29* 0.29* 0.39* 1998; van Wijngaarden et al., 2009), the IEQ demonstrated that
Factor III 0.25* 0.06 0.20*  0.06 0.19* women, partners and mothers, caregivers living with the ED patient,
and those with more weekly contact hours with the patient had
Data are given as Spearman correlation coefcients.
y
higher perceived caregiver burden. However, there are several non-
Numbers in bold represent the Cronbachs alpha coefcients.
signicant differences that warrant further evaluation in future
Correlations are statistically different from 0 (p o 0.05).
n

a
ABOS domains: Factor I, Eating behaviour, concern with weight and foods,
denial of problems; Factor II, Bulimic-like behaviour; Factor III, Hyperactivity.
et al., 2002; van Wijngaarden et al., 2004; van Wijngaarden et al.,
2009). We performed the CFA analysis with both options and,
since the results were similar in both cases, we maintained the
studies, as it could be expected, for instance, that caregivers with
more contact hours with the patients could feel more tension, or
those living with the patients could tend to supervise them more.
The responsiveness parameters were low in the unchanged
group and moderate in the improved group, which can be a
reection of the small changes detected by the questionnaire over
 N. Gonzalez et al. / Psychiatry Research 200 (2012) 896903 901

Table 4
Known-groups validity.

n IEQ scales

Tensiona Supervisiona Worryinga Urginga Total

Contact hours
o32 132 7.15 (5.09) 2.18 (3.19) 11.60 (5.80) 5.88 (3.74) 24.82 (13.02)
Z32 108 7.55 (4.24) 2.56 (4.22) 12.84 (5.90) 7.82 (4.98) 28.52 (13.36)
p value 0.146 0.326 0.083 0.003 0.028

Living with the patient

Yes 209 7.66 (4.58) 2.38 (3.67) 12.19 (5.69) 6.89 (4.36) 26.93 (12.92)
No 35 5.74 (5.67) 2.44 (4.42) 12.44 (7.00) 5.96 (4.93) 24.96 (16.33)
p value 0.004 0.143 0.891 0.115 0.198

Type of caregiver
Mother 111 7.83 (5.04) 2.76 (4.13) 13.42 (6.01) 7.20 (5.06) 28.78 (14.58)
Father 70 6.23 (3.89) 1.47 (2.72) 11.47 (5.90) 5.74 (3.75) 23.15 (12)
Spouse/partner 34 7.07 (4.12) 3.37 (4.61) 11.31 (4.86) 6.84 (3.77) 26.34 (11.51)
Others 31 8.86 (5.80) 1.91 (2.90) 10.81 (5.76) 7.29 (3.95) 27.23 (12.82)
p value 0.088 0.003 0.033 0.159 0.039

Gender
Female 131 7.98 (5.21) 2.70 (4) 13.14 (5.97) 7.32 (4.91) 28.80 (14.40)
Male 115 6.72 (4.13) 2.01 (3.45) 11.21 (5.60) 6.09 (3.75) 24.18 (11.75)
p value 0.081 0.042 0.008 0.106 0.006

Results are presented as means (standard deviations).

a
IEQ score ranges: Tension 036; Supervision 024; Worrying 024; Urging 032; Total 0108. p-values in bold represent statistically signicant differences.

Table 5
Responsiveness parameters after one year of follow-up, by change in the anxiety subscale of the HADS (n 143).

IEQ subscalesa

Tension Supervision Worrying Urging Total

Equal groupb
Mean (SD)y
Baseline 7.20 (4.37) 2.12 (3.66) 12.64 (5.89) 6.89 (4.49) 26.57 (13.20)
1 year follow-up 6 (4.45) 1.74 (3.39) 10.14 (6.27) 5.70 (4.40) 21.54 (13.61)
Change 1.16 (4.08) 0.36 (2.50) 2.63 (5.44) 1.24 (3.44) 4.86 (9.39)
p value 0.003 0.215 o 0.0001 0.0002 o0.0001
SES 0.27 0.10 0.45 0.28 0.37
SRM 0.28 0.14 0.48 0.36 0.52

Improved groupb
Mean (SD)y
Baseline 9.99 (6.11) 3.59 (4.93) 12.69 (5.61) 8.32 (4.60) 32.6 (15.35)
1 year follow-up 5.24 (3.45) 1.69 (2.92) 9.71 (6.15) 5.37 (3.10) 20.68 (11.74)
Change 4.75 (5.40) 1.87 (4.33) 2.98 (5.08) 2.71 (4.26) 11.91 (12.05)
p Value 0.0004 0.018 0.005 0.013 0.0001
SES 0.78 0.38 0.53 0.59 0.78
SRM 0.88 0.43 0.59 0.64 0.99

SD standard deviation; SES: standardized effect size; SRM: standardized response mean.
Changes were calculated by subtracting postintervention scores from preintervention scores; a positive result indicates a gain.
a
IEQ score ranges: Tension 036; Supervision 024; Worrying 024; Urging 032; Total 0-108.
y
Paired t-test to compare the mean at baseline and one year follow-up.
b
Equal group: those caregivers without changes in anxiety between baseline and follow-up, measured by the HADS; improved group: those caregivers who improved
in anxiety in the follow-up, measured by the HADS.

the course of one year on caregivers of ED patients. Other studies
using different questionnaires have also found small changes in
the health status of ED patients with the follow-up periods they
have used (Padierna et al., 2002; Las Hayas et al., 2007; Sepulveda
et al., 2008). If the mean evolution time for ED is 5 years
(Steinhausen, 2002; Steinhausen and Weber, 2009), the caregiver
burden perception could also need a longer follow-up period than
the one used in our study to detect clinically signicant changes.
Although the IEQ was initially developed for evaluating the
burden imposed by providing care to patients with schizophrenia,
this instrument has also been used with caregivers of patients
with affective disorders (van Wijngaarden et al., 2004; van
Wijngaarden et al., 2009) or brain injury (Geurtsen et al., 2010).
The authors of the IEQ began using it in psychosis, then used it for
affective disorders without validating it again, as they stated
there were some similarities between these two disorders that
could demonstrate its suitability for depression. In the case of
brain injury, the authors performed a psychometric analysis
which yielded results similar to ours, with good reliability
estimates (Cronbachs alpha coefcients between 0.69 and 0.76),
low correlations with other questionnaires (r coefcient range
 0.29 0.40) and weak effect sizes (Cohens d effect size of 0.36).
Several instruments have been developed specically for ED
caregivers. The Carers Needs Assessment Measure (CaNAM) uses
14 items to evaluate the needs of ED carers (Haigh and Treasure,
2003). The Accommodation and Enabling Scale for Eating
902 N. Gonzalez et al. / Psychiatry Research 200 (2012) 896903
Disorders (AESED) measures families behaviours of accommoda-
tion and enabling using 33 items (Sepulveda et al., 2009). Neither
of these instruments, however, measure caregiver burdenthe
CaNAM measures met and unmet needs and the AESED evaluates
families behaviours. In contrast, the 24-item Eating Disorders
Symptom Impact Scale (EDSIS) was created specically to evalu-
ate the burden and consequences of caring for a family member
with an ED (Sepulveda et al., 2008). Looking at the construct
measured by each questionnaire, the EDSIS could be the best to t
the aim of our study. However, EDSIS results had not been
published when we began our study. At that time, the IEQ
appeared to be the best instrument available, so we decided to
validate it in our sample of caregivers of patients with ED.
Both the EDSIS and the IEQ have four domains and a similar
number of items (24 and 27, respectively). The EDSIS domains
emphasise patient symptoms (nutrition, guilt, dysregulated beha-
viour, and social isolation) while the IEQ emphasises the experi-
ence of the caregiver (tension, supervision, worrying, and urging).
The validity and reliability of both instruments are good, making
either one an appropriate choice for the perceived burden and
consequences of providing care to an ED patient. Even more, both
could be combined in the same study in order to evaluate if they
really evaluate the same or complementing concepts.
Our study also has some limitations that should be mentioned.
We evaluated the reliability of the IEQ by using Cronbachs alpha
coefcient to measure the internal consistency. More evidence of
the stability of the scores could be added with a testretest study.
The responsiveness parameters were weaker in the unchanged
group, which has some face validity. As other studies have
demonstrated good reliability data from the IEQ, the HADS, and
the SF-12 (Van Wijngaarden et al., 1996; Schmitt and Di Fabio,
2004; Cameron et al., 2008), our results support the hypothesis
that the responsiveness data of the IEQ in our sample can be due
to the small changes that the patients and their caregivers
experienced over the course of one year, and not to the
questionnaires inability to detect changes.
As in any prospective cohort study, missing data is another
limitation, especially with regard to the evaluation of responsive-
ness. In our study, the number of respondents after one year (143)
was lower than the number that began the study (246), and some
differences were observed between caregivers who provided
information at both baseline and one year later. Those patients
who answered at follow-up were mentally more affected, which
may have an effect on their perception of burden.
In future studies, apart from doing a testretest study and
establishing a longer follow-up period it could be helpful to add
an anchor variable at the follow-up period. This would allow the
evaluation of responsiveness by means of the minimal clinically
important difference (MCID), a more practical parameter that
clinicians could use to assess the importance of the detected
change. This would add evidence of the psychometric properties
of the IEQ.
A comparative study of the IEQ and the EDSIS could analyse
the differences and similarities between them, which could help
clinicians and researchers decide which one to use in studies of
caregiver burden and consequences.
In conclusion, among caregivers of patients with EDs, the IEQ
has good psychometric properties and can be used to understand
caregivers perception of burden and the consequences of provid-
ing care to an ED patient. Although it is already known that these
caregivers experience great strain (Treasure, 2004) and that the
patients for whom they care are inuenced by this burden
(Schmidt and Treasure, 2006), instruments designed to system-
atically detect it could help clinicians identify caregivers who
could need additional support and empowerment for their role as
caregivers.
Acknowledgments
This study was partly funded by the Instituto de Salud Carlos
III (project PI06/0921). We thank the Research Committee of the
Galdakao-Usansolo Hospital for help editing this article and the
editorial assistance provided by Patrick Skerrett. Also, we would
like to thank Dr. van Wijngaarden, one of the authors of the
original version of the Involvement Evaluation Questionnaire, for
answering all our questions in a very timely and precise way.
Most important, we are very grateful to the caregivers of patients
with eating disorders who collaborated in this study.
References
Batista-Foguet, J., Coenders, G., Alonso, J., 2004. Conrmatory factor analysis. Its
role on the validation of health related questionnaires. Medicina Clnica 122
(suppl. 1), 2127.
Cameron, I.M., Crawford, J.R., Lawton, K., Reid, I.C., 2008. Psychometric comparison
of PHQ-9 and HADS for measuring depression severity in primary care. British
Journal of General Practice 58, 3236.
Cleary, M., Hunt, G.E., Walter, G., Freeman, A., 2006. The patients view of need and
caregiving consequences: a cross-sectional study of inpatients with severe
mental illness. Journal of Psychiatric and Mental Health Nursing 13, 506514.
Cohen, J., 1992. A power primer. Psychological Bulletin 112, 155159.
Cronbach, L.J., 1951. Coefcient alpha and the internal structure of test. Psycho-
metrika 16, 297334.
Deeken, J.F., Taylor, K.L., Mangan, P., Yabroff, K.R., Ingham, J.M., 2003. Care for the
caregivers: a review of self-report instruments developed to measure the
burden, needs, and quality of life of informal caregivers. Journal of Pain and
Symptom Management 26, 922953.
Devins, G.M., Dion, R., Pelletier, L.G., Shapiro, C.M., Abbey, S., Raiz, L.R., Binik, Y.M.,
McGowan, P., Kutner, N.G., Beanlands, H., Edworthy, S.M., 2001. Structure of
lifestyle disruptions in chronic disease: a conrmatory factor analysis of the
Illness Intrusiveness Ratings Scale. Medical Care 39, 10971104.
Fayers, P.M., Machin, D., 2000. Quality of Life: Assessment, Analysis and Inter-
pretation. John Wiley & Sons Ltd., West Sussex, UK.
Gandek, B., Ware, J.E., Aaronson, N.K., Apolone, G., Bjorner, J.B., Brazier, J.E.,
Bullinger, M., Kaasa, S., Leplege, A., Prieto, L., Sullivan, M., 1998. Cross-
validation of item selection and scoring for the SF-12 Health Survey in nine
countries: results from the IQOLA Project. International Quality of Life
assessment. Journal of Clinical Epidemiology 51, 11711178.
Geurtsen, G.J., Meijer, R., van Heugten, C.M., Martina, J.D., Geurts, A.C.H., 2010.
Experienced emotional burden in caregivers: psychometric properties of the
Involvement Evaluation Questionnaire in caregivers of brain injured patients.
Clinical Rehabilitation 24, 935943.
Gonzalez, N., Padierna, A., Martin, J., Aguirre, U., Quintana, J.M., 2012. Predictors of
change in perceived burden among caregivers of patients with eating dis-
orders. Journal of Affective Disorders 139 (3), 273282.
Goossens, P.J.J., van Wijngaarden, B., Knoppert-van der Klein, E.A.M., van Achterberg,
T., 2008. Family caregiving in bipolar disorder: caregiver consequences, caregiver
coping styles, and caregiver distress. International Journal of Social Psychiatry 54,
303316.
Guillemin, F., Bombardier, C., Beaton, D., 1993. Cross-cultural adaptation of health-
related quality of life measures: literature review and proposed guidelines.
Journal of Clinical Epidemiology 46, 14171432.
Gutierrez-Maldonado, J., Caqueo-Urizar, A., Kavanagh, D.J., 2005. Burden of care
and general health in families of patients with schizophrenia. Social Psychiatry
& Psychiatric Epidemiology 40, 899904.
Haigh, R., Treasure, J., 2003. Investigating the needs of carers in the area of eating
disorders: development of the Carers Needs Assessment Measure (CaNAM).
European Eating Disorders Review 11, 125141.
Hatcher, L., 1994. Developing measurement models with conrmatory factor
analysis, A Step-by-Step Approach to Using the SASs System for Factor
Analysis and Structural Equation Modelling. SAS Institute Inc, Cary, NC.
Herrmann, C., 1997. International experiences with the hospital Anxiety and
Depression Scale: a review of validation data and clinical results. Journal of
Psychosomatic Research 42, 1741.
Hirst, M., 2005. Carer distress: a prospective, population-based study. Social
Science & Medicine 61, 697708.
Instituto Nacional de la Salud, 1995. Protocolo de trastornos del comportamiento
alimentario. Madrid, Instituto Nacional de la Salud, editor.
Kinsella, G., Cooper, B., Picton, C., Murtagh, D., 1998. A review of the measurement of
caregiver and family burden in palliative care. Journal of Palliative Care 14, 3745.
Las Hayas, C., Quintana, J.M., Padierna, J.A., Bilbao, A., Munoz, P., Cook, E.F., 2007.
Health-Related Quality of Life for Eating Disorders questionnaire version-2
was responsive 1-year after initial assessment. Journal of Clinical Epidemio-
logy 60, 825833.
Lazarus, R.S., Folkman, S., 1984. Stress, Appraisal and Coping. Springer Publishing,
Nueva York (Traduccion espanola: Estres y procesos cognitivos, Primera
Edicion. Martinez Roca, Barcelona 1986).
 N. Gonzalez et al. / Psychiatry Research 200 (2012) 896903
Lowyck, B., De Hert, M., Peeters, E., Wampers, M., Gilis, P., Peuskens, J., 2004.
A study of the family burden of 150 family members of schizophrenia patients.
European Psychiatry 19, 395401.
Martn, J., Padierna, A., Aguirre, U., Quintana., J.M., Las Hayas, C., Munoz, P., 2011.
Quality of life among caregivers of patients with eating disorders. Quality of
Life Research 20, 13591369.
Mulaik, S.A., 1989. Evaluation of goodness-of-t indices for structural equation
models. Psychological Bulletin 105, 430445.
Muthen, L.K., Muthen, B.O., 1998. Mplus Users Guide. Muthen & Muthen, Los
Angeles, CA.
Nunnally, J.C., Bernstein, I.H., 1994. Psychometric Theory, 3rd ed. McGraw-Hill,
New York.
Padierna, A., Quintana, J.M., Arostegui, I., Gonzalez, N., Horcajo, M.J., 2002. Changes
in health related quality of life among patients treated for eating disorders.
Quality of Life Research 11, 545552.
Padierna A., Martn J., Aguirre U., Gonzalez N., Munoz P., Quintana J.M. Burden of
caregiving amongst family caregivers of patients with eating disorders. Social
Psychiatry and Psychiatric Epidemiology, in press. .
Parabiaghi, A., Lasalvia, A., Bonetto, C., Cristofalo, D., Marrella, G., Tansella, M.,
Ruggeri, M., 2007. Predictors of changes in caregiving burden in people with
schizophrenia: a 3-year follow-up study in a community mental health
service. Acta Psychiatrica Scandinavica 116 (suppl. 437), 6676.
Perlick, D.A., Hohenstein, J.M., Clarkin, J.F., Kaczynski, R., Rosenheck, R.A., 2005.
Use of mental health and primary care services by caregivers of patients with
bipolar disorder: a preliminary study. Bipolar Disorders 7, 126135.
Platt, S., 1985. Measuring the burden of psychiatric illness on the family: an
evaluation of some rating scales. Psychological Medicine 15, 383393.
Quintana, J.M., Padierna, A., Esteban, C., Arostegui, I., Bilbao, A., Ruiz, I., 2003.
Evaluation of the psychometric characteristics of the Spanish version of the
Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica 107,
216221.
Roick, C., Heider, D., Toumi, M., Angermeyer, M.C., 2006. The impact of caregivers
characteristics, patients conditions and regional differences on family burden
in schizophrenia: a longitudinal analysis. Acta Psychiatrica Scandinavica 114,
363374.
Schene, A.H., van Wijngaarden, B., 1992. The Involvement Evaluation Question-
naire. Department of Psychiatry, University of Amsterdam, Amsterdam.
Schene, A.H., Tessler, R.C., Gamache, G.M., 1994. Instruments measuring family or
caregiver burden in severe mental illness. Social Psychiatry & Psychiatric
Epidemiology 29, 228240.
Schene, A.H., van Wijngaarden, B., Koeter, M.W.J., 1998. Family caregiving in
schizophrenia: domains and distress. Schizophrenia Bulletin 24, 609618.
Schmidt, U., Treasure, J., 2006. Anorexia nervosa: valued and visible. A cognitive-
interpersonal maintenance model and its implications for research and
practice. British Journal of Clinical Psychology 45, 343366.
Schmitt, J.S., Di Fabio, R.P., 2004. Reliable change and minimum important
difference (MID) proportions facilitated group responsiveness comparisons
using individual threshold criteria. Journal of Clinical Epidemiology 57,
10081018.
Sepulveda, A.R., Whitney, J., Hankis, M., Treasure, J., 2008. Development and
validation of an eating disorders symptom impact scale (EDSIS) for the
ecological assessment of carers of people with eating disorders. Health and
Quality of Life Outcomes 6, 28.
903
Sepulveda, A.R., Kyriacou, O., Treasure, J., 2009. Development and validation of the
Accommodation and Enabling Scale for Eating Disorders (AESED) for care-
givers in eating disorders. BMC Health Services Research 9, 171.
Steinhausen, H.C., 2002. The outcome of anorexia nervosa in the twentieth
century. American Journal of Psychiatry 159, 12841293.
Steinhausen, H.C., Weber, S., 2009. The outcome of bulimia nervosa: ndings from
a quarter of a century of research. American Journal of Psychiatry 166,
13311341.
Treasure, J., 2004. Review: exploration of psychological and physical health
differences between caregivers and non-caregivers. Evidence-Based Mental
Health 7, 28.
Van Wijngaarden, B., Schene, A.H., Koeter, M.W.J., 1996. The Consequences of
Depressive Disorders for Those Involved with the Patient: A Study of the
Psychometric Qualities of the Involvement Evaluation Questionnaire (in
Dutch). Department of Psychiatry, University of Amsterdam, Amsterdam.
van Wijngaarden, B., Schene, A.H., Koeter, M., Vazquez-Barquero, J.L., Knudsen,
H.C., Lasalvia, A., McCrone, P., 2000. Caregiving in schizophrenia: development,
internal consistency and reliability of the Involvement Evaluation
QuestionnaireEuropean Version. EPSILON Study 4. European Psychiatric
Services: Inputs Linked to Outcome Domains and Needs. British Journal of
Psychiatry Suppl 39, 2127.
Van Wijngaarden, B., Schene, A.H., Koeter, M.W.J., 2002. Caregiver consequences in
the Netherlands and other European countries: the development and use of
the Involvement Evaluation Questionnaire (IEQ). In: Leey, H.P., Johson, D.L.
(Eds.), Family Interventions in Mental Illness: International Perspectives.
Praeger Publishers, Westport, CT, pp. 145169.
van Wijngaarden, B., Schene, A.H., Koeter, M.W.J., 2004. Family caregiving
in depression: impact on caregivers daily life, distress, and help seeking.
Journal of Affective Disorders 81, 211222.
van Wijngaarden, B., Koeter, M., Knapp, M., Tansella, M., Thornicroft, G., Vazquez-
Barquero, J.L., Schene, A., 2009. Caring for people with depression or with
schizophrenia: are the consequences different? Psychiatry Research 169,
6269.
Vandereycken, W., 1992. Validity and reliability of the Anorectic Behavior
Observation Scale for parents. Acta Psychiatrica Scandinavica 85, 163166.
Vilagut, G., Valderas, J.M., Ferrer, M., Garin, O., Lopez-Garca, E., Alonso, J., 2008.
Interpretacion de los cuestionarios SF-36 y SF-12 en Espana: componentes
fsico y mental. Medicina Clnica 130, 726735.
Visser-Meily, J.M.A., Post, M.W.M., Riphagen, I.I., Lindeman, E., 2004. Measures
used to assess burden among caregivers of stroke patients: a review. Clinical
Rehabilitation 18, 601623.
Vitaliano, P.P., Young, H.M., Russo, J., 1991. Burden: a review of measures used
among caregivers of individuals with dementia. The Gerontologist 31, 6775.
Whalen, K.J., Buchholz, S.W., 2009. The reliability, validity and feasibility of tools
used to screen for caregiver burden: a systematic review. JBI Library of
Systematic Reviews 7, 13721429.
Ware Jr., J., Kosinski, M., Keller, S.D., 1996. A 12-item Short-Form Health Survey:
construction of scales and preliminary tests of reliability and validity. Medical
Care 34, 220233.
Zigmond, A.S., Snaith, R.P., 1983. The hospital anxiety and depression scale. Acta
Psychiatrica Scandinavica 67, 361370.