Archives of Psychiatric Nursing 32 (2018) 229–234
Contents lists available at ScienceDirect
Archives of Psychiatric Nursing
journal homepage: www.elsevier.com/locate/apnu
The Relationship Between the Burden of Caregiving, Submissive Behaviors
and Depressive Symptoms in Primary Caregivers of Patients With
Schizophrenia☆
⁎
Kerime Bademlia, , Neslihan Lökb, Ayten Kaya Kılıçc
a
Akdeniz University, Faculty of Nursing, Psychiatric Nursing Department, Antalya, Turkey
b
Selcuk University, Faculty of Health Science, Konya, Turkey
c
Antalya Kamu Hastaneleri Birligi Antalya Egitim A, Toplum Ruh Sagligi Merkezi, Antalya, Turkey
INTRODUCTION
Caregiving in schizophrenia is a demanding and exhausting activity
that challenges the physical and emotional resources of family care-
givers (Stanley, Balakrishnan, & Ilangovan, 2017). Family members
play an important role in providing care to patients with schizophrenia.
Many families who are faced with schizophrenia have complex feelings
and do not know the basics of caregiving. Therefore, caregivers adjust
to this situation after the family member develops a mental illness. A
primary caregiver is at the core of the patient's daily life. Thus, as the
levels of caregiving responsibilities increase, the relationship between
the provider and the one who is receiving the care can become a one-
way, dependent, heavy and long-term obligation that places an en-
ormous burden on the caregiver, and affects the quality of life (Atagün,
Balaban, Atagün, Elagöz, Özpolat, 2011). Caregivers of patients with
schizophrenia experience increased levels of rage, dissatisfaction, and
stress when they are obliged to take responsibility for the overall care of
the patient (Hayes, Hawthorne, Farhall, O'Hanlon, & Harvey, 2015).
The role of a caregiver is a challenging and unpredictable experience
that requires much effort and labor. Caregiving places a physical,
emotional and economic burden on the individual (McCann, Lubman,
Clark 2009). The risk of experiencing depression increases as the
caregivers' burden increases (Perlick et al., 2016).
Once the caregivers of patients with schizophrenia cannot cope ef-
fectively with the difficulties they experience, they feel a burden in
social, emotional, economic and physical aspects (Schulze & Rössler,
2006). The burden of the caregiver is categorized into two groups:
objective and subjective. The objective burden is described as the ob-
servable, concrete changes resulting from the disease. The subjective
burden, on the other hand, includes emotional difficulties that come out
of individual assessments regarding the caregiver and the disturbing
behavior of the patients (Brouwer et al., 2004). The higher the level of
burden that caregivers have, the more their mental health worsens
(Maldonado & Caqueo-Urízar, 2007). Several studies also suggest that
☆
The authors declare no conflict of interest.
⁎
Corresponding author at: Akdeniz University, Faculty of Nursing, Psychiatric Nursing Department Campus, Antalya 07058, Turkey.
E-mail address: kerimedemirbas@akdeniz.edu.tr (K. Bademli).
https://doi.org/10.1016/j.apnu.2017.11.007
Received 24 April 2017; Received in revised form 18 October 2017; Accepted 2 November 2017
0883-9417/ © 2017 Elsevier Inc. All rights reserved.
T
families who have a member with a chronic mental disorder are at a
high risk for experiencing mental health problems (Sintayehu, Mulat,
Yohannis, Adera, & Fekade, 2015; Stanley et al., 2017; Thunyadee,
Sitthimongkol, Sangon, Chai-Aroon, & Hegadoren, 2015). Sintayehu
et al. (2015) reported that there is a 56.7% possibility of observing
mental health problems among caregivers of patients with schizo-
phrenia. Another study that examined the mental health condition of
caregivers determined that caregivers are at a high risk of experiencing
mental health problems, such as depression or anxiety (Thunyadee
et al., 2015). In a study conducted in the USA with Latin families, the
rate of observing depression among caregivers of patients with schi-
zophrenia was found to be 40% (Magaña, Ramírez García, Hernández,
& Cortez, 2007).
Studies have shown that the burden of care giving is evident to-
gether with depression and stress symptoms (Chen & Lukens, 2011; El-
Tantawy, Raya, & Zaki, 2010; Magaña et al., 2007). Caregivers use
effective and ineffective methods to cope with the burden, depression
and stress symptoms (Ozlu, Yildiz, & Aker, 2015). A study reported that
the self-confident, helpless, and submissive behavior approach styles of
the caregivers who had a high care burden were observed as being used
more often (Aylaz & Yıldız, 2017). Magliano et al. (2002) examined the
factors that affect coping strategies used by caregivers of patients with
schizophrenia and reported that caregivers, particularly those with a
low level of social support, exhibit submissive behaviors which are one
of the most ineffective coping methods (Magliano et al., 2002). Sub-
missive behaviors may be viewed as non-hostile, non-coercive behavior
characterized by considering the power, authority, or feelings of others,
while denying or not standing up for one's own feelings and beliefs
(Deluty, 1985). In a study conducted by Pearson, Watkins, and Mullan
(2010) found that submissive behavior may mediate the effect on future
depression.
Examining the relationship between the burdens of caregivers, their
submissive behaviors and depression will allow for the development of
interventions and program content that will help caregivers effectively
K. Bademli et al.
cope with their burdens, and acquire coping methods to maintain and
improve their mental health conditions. Thus, this study aims to de-
termine the relationship between the burden of caregiving, submissive
behavior and depressive symptoms in primary caregivers of individuals
with patients with schizophrenia.
RESEARCH QUESTIONS
1. Are the sociodemographic characteristics of caregivers related to the
burden of caregiving?
2. Are the sociodemographic characteristics of caregivers related to
submissive behavior?
3. Are the sociodemographic characteristics of caregivers related to
their depression levels?
4. Is there a relationship between the burden of caregiving, submissive
behavior and depression levels of caregivers?
METHOD
STUDY DESIGN
This study was conducted using a descriptive correlational design.
STUDY PLACE AND ITS FEATURES
The study was conducted in Aşır Aksu Community Mental Health
Center in the Antalya Training and Research Hospital. This center was
established in 2012 to support patients with schizophrenia and their
relatives. Aşır Aksu Community Mental Health Center was founded in
2012 to provide support to patients with schizophrenia and their re-
latives. The center has a group therapy area, occupational therapy
rooms, and a reading room, and computer room, patient observation
room, sports fields, interview room and resting room. Moreover, ve-
getables and fruits are grown in the garden of the center for the purpose
of occupational therapy. The center employs two nurses, one social
service specialist, one psychologist, one mental health and diseases
specialist, an occupational therapist, a qualified instructor (public
education center teachers), medical secretary, one cleaning staff
member, driver, and security guard. The center provides services for
patients with schizophrenia every day except weekends.
THE SAMPLE OF THE STUDY
The population of the study included the relatives of patients re-
gistered in the Aşır Aksu Community Mental Health Center at the
Antalya Training and Research Hospital. The sample of the study was
calculated through a sampling method with unknown prevalence and
the sample was found to be 101 people, taking into consideration a
confidence interval of 95%, a standard deviation of 10% and a power
level of 90%.
INCLUSION CRITERIA
– Being literate (able to understand and complete survey forms)
– Living with the patient for at least six months and being the primary
caregiver
EXCLUSION CRITERIA
Not having any mental disorder.
VARIABLES
The independent variables in the present study included age, sex,
marital status, educational level, duration of care and the degree of
closeness to the patient, whereas the dependent variables included the
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Archives of Psychiatric Nursing 32 (2018) 229–234
burden of caregiving, submissive behavior, and depression level.
ETHICAL CONSIDERATIONS
Prior to conducting this study, ethical approval was obtained from
the Ministry of Health Turkey Public Hospitals Institution, the Antalya
Province Public Hospitals Association Secretary General and the
Antalya Training and Research Hospital Clinical Studies Ethics
Committee. Furthermore, the topic, objective, duration, and design of
the study were explained to the participants, and written consent was
obtained from them after they were informed.
DATA COLLECTION TOOLS
The data were collected using an introductory information form that
was prepared by the researchers to inquire about sociodemographic
characteristics. The Zarit Caregiver Burden Scale, the Submissive Acts
Scale and the Beck Depression Inventory and form were also used.
ZARIT CAREGIVER BURDEN SCALE
This scale was developed by Zarit, Reever, and Bach-Peterson
(1980), and it is utilized to examine the stress of those who provide care
to individuals with special needs, or to older adults. The scale can be
completed by the caregivers or the researchers through asking ques-
tions. It consists of 22 statements that determine the effect of caregiving
on the individual's life. This was a Likert-type scale including items
scored from “0” to “4”, which refer to never, rarely, often or almost
every time (Zarit & Zarit, 1990). A minimum of 0 (zero) points and a
maximum of 88 points can be obtained from the scale. The scale has no
cut-off point. Scale items reference social and emotional concerns.
Higher scale points mean the respondents have a higher level of diffi-
culty (İnci, 2006; Zarit & Zarit, 1990). The validity of the Caregiver
Burden Scale was examined by Fadime Hatice İnci in 2006 using the
language equivalence, content equivalence and structural equivalence
methods of the scale; the reliability of the scale was examined using
internal consistency, item analysis and test- retest reliability methods.
The internal consistency coefficient of the scale was found to range
from 0.87 to 0.94, its test-retest reliability was found to be 0.71 (İnci,
2006). The alpha score obtained in this study was 0.79.
SUBMISSIVE ACTS SCALE
The Submissive Acts Scale (SAS) was developed by Gilbert and Allan
(1994) to evaluate submissive social behaviors regarding depression.
This scale can be used for both adolescents and adults, and individuals
can administer it by themselves. Regarding each item, they are asked to
what extent the relevant behaviors describe themselves. They are re-
quested to answer the questions using the following statements: “de-
scribes not at all”, “describes a little”, “describes a fair amount”, “de-
scribes well” and “describes very well”. The items are evaluated based
on the five-point Likert-type scoring that ranges from 1 to 5 points.
Cronbach's alpha internal consistency score was found to be 0.89 and
test-retest reliability coefficient was found to be 0.84. The scale was
adapted to Turkish by Savaşır and Şahin in 1997 and they found
Cronbach's alpha internal consistency score to be 0.74. The scale con-
sists of 16 items and it has no cutoff score. A minimum of 16 and a
maximum of 80 points can be obtained from this scale. High scores refer
to more submissive behaviors (Savaşır & Şahin, 1997). The alpha score
obtained in this study was 0.83.
BECK DEPRESSION INVENTORY
The Beck Depression Inventory (BDI) is composed of 21 items. It
was developed to evaluate the intensity of several depressive symp-
toms, and to measure somatic, cognitive and motivational factors. This
K. Bademli et al. Archives of Psychiatric Nursing 32 (2018) 229–234

test is frequently used in epidemiological research, and in the evalua- Table 1

tion of treatment. The items are related to depressive symptoms and Distribution of sociodemographic data of caregivers and patients.
behaviors, and each item is scored between 0 and 3. The first form of
Variables Mean ± SD
the inventory was developed in 1961, and it was revised in 1978. There
is a high correlation between the two forms. The scale was tested for Caregiving
validity and reliability in Turkish by Hisli, and the cutoff score of BDI Age (Year) 55.89 ± 11.94
Maintenance period (Year) 14.83 ± 9.03
was accepted to be 17. The reliability coefficient of the scale was
n %
α = 0.92 (Savaşır & Şahin, 1997). The scores are categorized as fol- Gender
lows: 0 to 13 points, minimal depression; 14 to 19 points, mild de- Female 86 87.7
pression; 20 to 28 points, moderate depression; 29 to 63 points, severe Male 15 12.3
depression (Savaşır & Şahin, 1997). The subscales are as follows: de- Educational status
Literate 34 34.2
pressive mood, pessimism, sense of failure, joylessness, sense of guilt,
Primary education 54 54.8
self-dissatisfaction, self-incrimination, ideas of suicide, crying spells, High school and above 15 11.0
irritability, social withdrawal, distortion of body image, inability to The degree of proximity
work, sleep disorder, fatigue, loss of appetite, weight loss, somatic Mom 64 64.4
Other⁎⁎ 37 35.6
complaints, loss of libido and thoughts of punishment (Hisli, 1988). The
alpha score obtained in this study was 0.87.

Variables Mean ± SD
DATA COLLECTION
Patient's
The data were collected by the researchers through the face-to-face Age 38.30 ± 10.16
interview method. The data collection was performed until the sample, Duration of care (months) 15.10 ± 8.32
n %
which was determined using the basic random sampling method, was
Gender
reached. The data of the study were collected making home visits and Female 36 34.2
from the caregivers coming to the institution. During data collection, Male 65 65.8
the researchers gave informed consent forms to the relatives who
* ⁎⁎
agreed to participate in the research, to ensure that they read and un- p < 0,05. Other (Brother, wife and children are included)

derstood the scope and objective of this study. Those who confirmed
their participation were asked to sign these forms. Before the forms Table 2
Distributions of mean scores of caregivers obtained from the scales (n:101).
used in the present study were given, necessary explanations were
made verbally, and attention was paid to create a quiet setting where Scales Mean ± SD Range of points
the stimuli were few. It took 20 min on an average to complete a survey
form. Each participant signed an informed consent form reporting that Burden of caregiving 56.13 ± 20.05 0–88
Submissive behavior 49.90 ± 13.63 16–80
they received all the information related to this study and confirmed it. Depression inventories 39.21 ± 10.72 0–63

DATA EVALUATION
The data were analyzed using the IBM 21 software package.
Additionally, sociodemographic data were compared with the Zarit
Caregiver Burden Scale, the Submissive Acts Scale and the Beck
Depression Inventory scales using independent samples t-test and one-
way ANOVA. The relationship between the Zarit Caregiver Burden
Scale, the Submissive Acts Scale and the Beck Depression Inventory
scales was evaluated using the Pearson correlation analysis. The results
were assessed with a confidence interval of 95% and a significance level
of p < 0.05.
FINDINGS
The introductory sociodemographic characteristics of the caregivers
who participated in the study were examined, and the mean age was
found to be 55.89 ± 11.94. Of these, 87.7% were females, 54.8% had
completed a primary education, 93.2% did not have a work life, and
72.6% were married. The mean number of children they had was found
to be 3.34 ± 1.74. Of the participants, 53.4% had a chronic disorder.
Regarding the type of relationship with the patient, 64.4% were mo-
thers of the patients, and they had provided care for duration of
14.83 ± 9.03 years. The mean age of those who received care was
found to be 38.30 ± 10.16. Of them, 65.8% were males. Those who
received care were also observed to have needed care for
15.10 ± 8.32 years (Table 1).
Regarding the caregivers, the mean score of the burden of car-
egiving was found to be 78.13 ± 20.05, the mean score of submissive
behaviors was found to be 49.90 ± 13.63, and the mean score of de-
pression was found to be 39.21 ± 10.72 (Table 2).
Introductory sociodemographic characteristics were compared with
the mean scores of the burden obtained from the caregiving scale, those
who were married (59.47 ± 18.62), literate (63.36 ± 18.57) and
mothers of the patients (58.78 ± 18.99) were found to have higher
mean scores regarding the burden of caregiving, and the difference was
observed to be statistically significant (p < 0.05). A statistically sig-
nificant difference was found between the duration of caregiving and
the mean score of the burden of caregiving, which was evident when
the duration of caregiving was 21 years and over (55.64 ± 19.79)
(p < 0.05) (Table 3).
Introductory sociodemographic characteristics and the mean scores
of the Submissive Acts Scale were compared, and females
(51.03 ± 13.34) were found to be more submissive, and have higher
mean scores of submissive behaviors. The difference was observed to be
statistically significant (p < 0.05). Those who were married
(51.35 ± 14.09), literate (59.24 ± 12.30) and mothers of the pa-
tients (54.04 ± 12.92) were found to have higher mean scores of
submissive behaviors, and the difference was observed to be statisti-
cally significant (p < 0.05). No statistically significant difference was
found between the duration of caregiving and the mean score of sub-
missive behavior between groups (p > 0.05) (Table 3).
Introductory sociodemographic characteristics and the mean scores
of the depression scale were compared, and a statistically significant
difference was found between the mean scores of the depression scale
and age groups, those who were literate (41.92 ± 11.54) and mothers
of the patients (40.34 ± 10.34) were found to have higher mean scores
regarding the burden of caregiving, and the difference was observed to
be statistically significant (p < 0.05). No statistically significant dif-
ference was found between the factors of gender and marital status, and
the duration of caregiving, and the mean scores of the depression scale

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K. Bademli et al. Archives of Psychiatric Nursing 32 (2018) 229–234

Table 3 DISCUSSION
Comparison of introductory sociodemographic characteristics of caregivers with the mean
scores of the burden of caregiving, submissive behavior and depression inventories
This study sought to understand the consequences of family car-
(n:101).
egiving to patients with schizophrenia. Caring for patients with schi-
Burden of Submissive Beck Depression zophrenia has been associated with numerous negative mental health
caregiving behavior scales Inventory outcomes. The sociodemographic characteristics of the study showed
that most caregivers participating in the study were female, married,
Gender
Female 56.06 ± 19.68 51.03 ± 13.34 39.35 ± 11.00 primary school graduates, and unemployed.
Male 56.66 ± 23.83 41.88 ± 13.65 38.22 ± 8.92 A statistically significant difference was found between the duration
Test value, p t = 1.919 t = 0.084 t = 0.296 of caregiving and the mean score of the burden of caregiving. Regarding
p = 0.59 p < 0.001 p = 0.76 duration of time spent to look after patient, the present study results
Marital status
indicated that length of contact positively correlated with burden in
Married 59.47 ± 18.62 51.35 ± 14.09 38.84 ± 9.94
Single 54.60 ± 23.60 46.05 ± 11.78 40.20 ± 12.80 caregiver. The higher the duration of contact for taking care of their ill
Test value, p t = 0.925 t = 01.289 t = 0.478 relative, the greater burden the caregivers experienced. When a care-
p = 0.03 p = 0.03 p = 0.08 giver spends time with their ill relative, it may result in having less time
Educational
for themselves. As in this study, Chang, Chiou, and Chen (2010) found
status
Literate 63.36 ± 18.57 59.24 ± 12.30 41.92 ± 11.54 when care is provided for a longer duration of time caregivers experi-
Primary 55.87 ± 19.86 47.42 ± 10.84 37.60 ± 9.55 ence burden.
education This study showed that women, particularly mothers, consider
High school 53.12 ± 24.50 33.12 ± 8.27 38.87 ± 13.28 themselves to have higher levels of the burden of caregiving. They also
and above
exhibit more submissive behavior and symptoms of depression; how-
Test value, p F = 1.366 F = 18.818 F = 0.289
p = 0.012 p < 0.001 p = 0.028 ever, this finding can reflect the disproportionate over-representation of
Maintenance women in the sample. A review study reported that, in the epidemio-
period logical data women, and most frequently the mother, are the principal
(years)
caregivers in schizophrenia this can be attributed to gender role ex-
1–10 years 58.82 ± 19.95 49.20 ± 14.85 39.58 ± 12.52
11–20 years 58.96 ± 20.94 51.59 ± 13.37 38.81 ± 8.83
pectations that females should assume a primary caregiving role (Awad
21 years and 55.64 ± 19.79 48.41 ± 12.28 39.23 ± 10.75 & Voruganti, 2008. Similar in traditional Turkish culture the role of
over mother tends to require the female to be the primary caregiver for a
Test value, p F = 0.167 F = 0.341 F = 0.846 family member with mental illness. These gender differences may be
p = 0.011 p = 0.712 p = 0.965
related to traditional Turkish culture. Gender role for females and its
The degree of
proximity association with caregiver's submissive behavior and burden may be
Mom 58.78 ± 18.99 54.04 ± 12.92 40.34 ± 10.34 increased risk for depression. A cross-sectional, descriptive study con-
Othera 56.96 ± 22.18 42.42 ± 11.72 37.19 ± 11.29 ducted by Hsiao and Tsai (2015) found that the burdens of female
Test value, p t = 0.370 t = 3.799 t = 0.232
caregivers are greater than those of men at a statistically significant
p = 0.031 p < 0.001 p = 0.001
level. Given that females are socially and culturally predisposed to
F: OneWay ANOVA test (Post hoc: Bonferonni), t: t-test in independent groups. taking on the caregiving role and performing a greater variety of tasks,
a
Other (brother, wife and children are included). they are more submissive role overload and overload related burden. It
may also be considered that submissive behavior is regarded as a sign of
(p > 0.05) (Table 3). respect in Turkish culture and people often mistake submissiveness for
The relationship between the age of caregiver, the burden of car- being respectful.
egiving, submissive behaviors and depression levels of caregivers was Those who are over 30 years old also report a higher burden of
examined. No relationship was found between age and the burden of caregiving, and exhibit more submissive behaviors and depressive
caregiving (r = 0.139 p = 0.24), whereas a positive relationship was symptoms. Studies showed that mothers, caregivers with depressive
observed between submissive behavior (r = 0.496 p = 0.01) and de- symptoms, and caregivers with a higher self- perceived stigma are more
pression levels (r = 0.597 p = 0.03) and age. The burden of caregiving likely to experience a higher level of caregiver burden (Chen & Lukens,
was found to be related to the Submissive Acts Scale in a moderately 2011; Magaña et al., 2007). No significant relationship was found be-
positive way (r = 0.557 p = 0.001) and to the depression scale in a tween the age of caregivers and the burden they experienced. Some
moderately positive way (r = 0.489 p = 0.001), while the Submissive studies showed that the caregivers' ages, marital status, education, and
Acts Scale was found to be significantly positively related to the de- employment have a variable effect on burden (Chan, 2011; Kate,
pression scale (r = 0.797 p = 0.011) (Table 4). Grover, Kulhara, & Nehra, 2013). Moreover, the present study corro-
borated some other studies that suggested that the ages of the caregiver
were not significantly correlated with the burden (Gupta, Isherwood,
Jones, & Van Impe, 2015; Stanley et al., 2017). As stated in many
Table 4 studies conducted in this field, burden perceived by the caregivers of
The relationship between the mean scores of the age, burden of caregiving, submissive
behaviors and depression levels of caregivers (r, p) (n:101).
patients with schizophrenia is a universal experience. The variables
related to the burden perceived may differ.
Age Burden of Submissive Depression level Mean caregiver burden scores in this study were similar to the
caregiving behavior finding of Alexander et al. (2016) indicating a slightly moderate level of
Age 1.00
burden. The finding of high perceived burden in caregivers of a patient
Burden of r = 0.139 1.00 with schizophrenia in this study is in agreement with several studies
caregiving (Hsiao & Tsai, 2015; Zahid & Ohaeri, 2010). As can be seen from the
⁎
Submissive r = 0.496 r = 0.557⁎ 1.00 findings obtained from several studies, caregivers of patients with
behavior
⁎ ⁎
schizophrenia experience different levels of burden. In summary, stu-
Depression r = 0.597 r = 0.489 r = 0.797⁎ 1.00
level dies on the family caregivers of a patient with schizophrenia indicate
that schizophrenia is a chronic burden to families, and is not limited to
⁎
p < 0.05, r: Pearson correlation test. specific societies or cultures. This finding is important to consider when

232
K. Bademli et al.
developing plans to determine the needs of caregivers, and provide
support. The literature supports that family caregivers' burden is a
multidimensional phenomenon, involving their mental health, physical
condition, social life, and financial status and the functioning of the
family. The social context and family's experience within this context
should be examined while analyzing the caregiver's burden (Chan,
2011).
Another finding from this study was that half of the caregivers of
patients with schizophrenia exhibited submissive behaviors during the
caregiving process and there was a significant relationship between the
burden of care and submissive behavior. Bastawrous (2013) also in-
dicated a significant relationship between the burden experienced by
caregivers and submissive behaviors. Studies conducted in Turkey re-
vealed that caregivers of patients with schizophrenia exhibited sub-
missive behaviors in order to cope with the difficulties they experienced
(Aylaz & Yıldız, 2017; Bademli & Duman, 2014). Studies on submissive
behaviors suggest that culture has an important role in the occurrence
of such behaviors (Türküm, 2005). Turkish culture prescribes a less
assertive and more submissive role for females, which limits their
ability to verbalize their complaints and concerns. This can be ex-
plained by the fact that most caregivers in this study were females. It
may also be considered that a submissive attitude is regarded as a sign
of respect in the Turkish culture, and people often mistake submis-
siveness for respect. Since females are socially and culturally predis-
posed to taking on the caregiving role and performing a greater variety
of domestic tasks, they are more vulnerable to feeling overwhelmed and
overloaded with the ‘burden’ of caregiving. These findings supported
the conclusion that caregivers exhibited submissive behaviors as an
ineffective coping method. Using ineffective coping methods to deal
with stress may lead to experiencing chronic stress. As a result, care-
givers may become depressed.
This study revealed that almost half of the caregivers suffered from
depression. Similarly, studies evaluating the mental health conditions
of caregivers of patients with schizophrenia found a high rate of in-
cidence of depression (Gupta et al., 2015; Rodrigo, Fernando,
Rajapakse, De Silva, & Hanwella, 2013; Van Wijngaarden, Schene, &
Koeter, 2004). Perlick et al. (2016) reported that higher levels of the
overall caregiver burden at the baseline measurement were associated
with increased levels of depressive symptoms among caregivers. Simi-
larly, in this study, caregivers with heavier burdens of caregiving were
observed to have more submissive behaviors and depressive symptoms.
Another study suggested that high levels of burden experienced by
caregivers of patients with schizophrenia are associated with high levels
of anxiety and depression (Stanley et al., 2017). Burden, self-controlling
coping strategies and physical health status are all independently pre-
dictive of depressive symptoms for the caregivers of patients with
schizophrenia (Thunyadee et al., 2015). Therefore, nurses should
gather information regarding the coping strategies used by the family
caregivers to assess their impact on caregiver burden and risk for de-
pression. Moreover, family intervention programs are needed to assist
caregivers in dealing with stressors that lead to increased burden,
submissive behavior, and depression resulting from the care of in-
dividuals with schizophrenia.
STUDY LIMITATIONS
This study is limited to patients registered at the Aşır Aksu
Community Mental Health Center at the Antalya Training and Research
Hospital, as well as their relatives who complied with the sampling
criteria, and agreed to participate in the research. The number of
variables affecting the burden of caregiving, depression, and submissive
behavior status examined in the present study was limited. In this re-
spect, the variables related to the number of persons involved in the
caregiving, other care recipients of the primary caregiver, family sup-
port, income, attitude when initiated caregiving, as well as current at-
titude, should be examined more comprehensively.
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Archives of Psychiatric Nursing 32 (2018) 229–234
CONCLUSION AND RECOMMENDATIONS
This study concluded that the burden of caregiving was found to be
moderately positively related to submissive behavior and depression,
and submissive behavior was found to be significantly positively related
to depression. Individuals with heavier burdens of caregiving were
observed to exhibit more submissive behaviors and depressive symp-
toms. Moreover, this study could be the first step in developing good
strategies to reduce the caregiver burden, depression, and submissive
behavior. Caregiver of the patient with schizophrenia may benefit from
interventions that promote coping skills to enhance or maintain their
mental health. The findings from this study provide direction for in-
terventions for the caregiver of the patient with schizophrenia.
Psychiatric-mental health nurses can readily teach adaptive coping
skills to regulate the caregivers' burden of caregiving, submissive be-
haviors, and depression as a part of their health promotion and edu-
cation practices in clinical areas or community settings. Future studies
should focus on examining the burden, depression, and submissive
behavior of families in various regions and cultures, which include the
strengths and protective factors.
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