Randomized trial comparing caregiver-only family-focused treatment to standard health education on the 6-month outcome of bipolar disorder.

OBJECTIVES: Caregivers of people with bipolar disorder often have depression and health problems. This study aimed to evaluate the sustained effects of a 12-15 week psychoeducational intervention on the health and mental health of caregivers of persons with bipolar disorder. We also evaluated the effects of the intervention on patients' mood symptoms over 6 months post-treatment. METHODS: Caregivers of 46 persons with bipolar disorder were randomized to 12-15 weeks of a caregiver-only adaptation of family-focused treatment (FFT), in which caregivers were instructed on self-care strategies and ways to assist the patient in managing the illness, or to 8-12 sessions of standard health education. Independent evaluators assessed caregivers' depression and physical health and patients' mood symptoms before treatment, immediately after the treatment, and at 6 months post-treatment. RESULTS: Randomization to FFT was associated with greater decreases in depression for both caregivers and patients over a 6-month follow-up period post-treatment. Reductions in patients' depression scores over 6 months post-treatment were mediated by reductions in caregivers' depression scores (z = -2.74, P < .01). CONCLUSIONS: Interventions that are effective in reducing mood symptoms and improving health behavior in caregivers may have important health and mental health benefits for patients with bipolar disorder. Specifically, a treatment focused on caregiver education about bipolar disorder and the need for the caregiver to attend to his/her own health and mental health can benefit patients, even without their direct participation.

The incorporation of emotion-regulation skills into couple- and family-based treatments for post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) is a disabling, potentially chronic disorder that is characterized by re-experience and hyperarousal symptoms as well as the avoidance of trauma-related stimuli. The distress experienced by many veterans of the Vietnam War and their partners prompted a strong interest in developing conjoint interventions that could both alleviate the core symptoms of PTSD and strengthen family bonds. We review the evolution of and evidence base for conjoint PTSD treatments from the Vietnam era through the post-911 era. Our review is particularly focused on the use of treatment strategies that are designed to address the emotions that are generated by the core symptoms of the disorder to reduce their adverse impact on veterans, their partners and the relationship. We present a rationale and evidence to support the direct incorporation of emotion-regulation skills training into conjoint interventions for PTSD. We begin by reviewing emerging evidence suggesting that high levels of emotion dysregulation are characteristic of and predict the severity of both PTSD symptoms and the level of interpersonal/marital difficulties reported by veterans with PTSD and their family members. In doing so, we present a compelling rationale for the inclusion of formal skills training in emotional regulation in couple-/family-based PTSD treatments. We further argue that increased exposure to trauma-related memories and emotions in treatments based on learning theory requires veterans and their partners to learn to manage the uncomfortable emotions that they previously avoided. Conjoint treatments that were developed in the last 30 years all acknowledge the importance of emotions in PTSD but vary widely in their relative emphasis on helping participants to acquire strategies to modulate them compared to other therapeutic tasks such as learning about the disorder or disclosing the trauma to a loved one. We conclude our review by describing two recent innovative treatments for PTSD that incorporate a special emphasis on emotion-regulation skills training in the dyadic context: structured approach therapy (SAT) and multi-family group for military couples (MFG-MC). Although the incorporation of emotion-regulation skills into conjoint PTSD therapies appears promising, replication and comparison to cognitive-behavioral approaches is needed to refine our understanding of which symptoms and veterans might be more responsive to one approach versus others.

Caregiver burden as a predictor of depression among family and friends who provide care for persons with bipolar disorder.

OBJECTIVES: Over one-third of caregivers of people with bipolar disorder report clinically significant levels of depressive symptoms. This study examined the causal relationship between depression and caregiver burden in a large sample of caregivers of adult patients with bipolar disorder. METHODS: Participants were 500 primary caregivers of persons with bipolar disorder enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).This study evaluates the strength and direction of the associations between caregiver burden and depressive symptoms at baseline and at six- and 12-month follow-up using cross-lagged panel analyses, controlling for the clinical status of patients and sociodemographic variables. RESULTS: Higher levels of overall caregiver burden at baseline were associated with increased levels of depressive symptoms among caregivers at follow-up (F = 8.70, df = 1,290, p < 0.001), after controlling for baseline caregiver depression, gender, race, age, social support, and patients' clinical status. By contrast, caregiver depression at baseline was not significantly associated with caregiver burden at follow-up (F = 1.65, p = 0.20). CONCLUSIONS: Caregiver burden is a stronger predictor of caregiver depressive symptoms over time than the reverse. Interventions that help alleviate caregiver burden may decrease depressive symptoms.

The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care.

Treatments have been developed and tested to successfully reduce the symptoms and disabilities of many mental illnesses. Unfortunately, people distressed by these illnesses often do not seek out services or choose to fully engage in them. One factor that impedes care seeking and undermines the service system is mental illness stigma. In this article, we review the complex elements of stigma in order to understand its impact on participating in care. We then summarize public policy considerations in seeking to tackle stigma in order to improve treatment engagement. Stigma is a complex construct that includes public, self, and structural components. It directly affects people with mental illness, as well as their support system, provider network, and community resources. The effects of stigma are moderated by knowledge of mental illness and cultural relevance. Understanding stigma is central to reducing its negative impact on care seeking and treatment engagement. Separate strategies have evolved for counteracting the effects of public, self, and structural stigma. Programs for mental health providers may be especially fruitful for promoting care engagement. Mental health literacy, cultural competence, and family engagement campaigns also mitigate stigma's adverse impact on care seeking. Policy change is essential to overcome the structural stigma that undermines government agendas meant to promote mental health care. Implications for expanding the research program on the connection between stigma and care seeking are discussed.

Family members' of persons living with a serious mental illness: experiences and efforts to cope with stigma.

BACKGROUND: Studies have indicated that family members of persons with mental illness often experience stigma in relation to their relatives' illness. Less is known about the type of experiences they face and how they cope with these experiences. AIMS: To explore family members' experiences and efforts to cope with mental illness stigma in social encounters. METHOD: A qualitative immersion/crystallization analysis of focus group data was used to examine family members' experiences and responses to perceived stigma. RESULTS: Family members reported experiencing rejection, blame and avoidance by others, engendering hurt, disappointment and shame. They employed flexible coping strategies depending on their personal resources, motivation and their relatives' willingness to disclose. CONCLUSION: Findings suggest that families learn from their own experience the "art of selective disclosure": what, when, how much and who to share information with. Coping strategies are developed based on the situation and family members' needs and personal resources which differ between families and over time.

Implementation of multifamily group treatment for veterans with traumatic brain injury.

OBJECTIVE: This study evaluated the initial efficacy and feasibility of implementing multifamily group treatment for veterans with traumatic brain injury (TBI). METHODS: Veterans at two Veterans Affairs medical centers were prescreened by their providers for participation in an open trial of multifamily group treatment for TBI. Enrollment was limited to consenting veterans with a clinical diagnosis of TBI sustained during the Operation Enduring Freedom-Operation Iraqi Freedom era, a family member or partner consenting to participate, and a score ≥20 on the Mini-Mental State Examination. The nine-month (April 2010-March 2011) trial consisted of individual family sessions, an educational workshop, and bimonthly multifamily problem-solving sessions. Interpersonal functioning and symptomatic distress among veterans and family burden, empowerment, and symptomatic distress among families were assessed before and after treatment. RESULTS: Providers referred 34 (58%) of 59 veterans screened for the study; of those, 14 (41%) met criteria and consented to participate, and 11 (32%) completed the study. Severity of TBI, insufficient knowledge about the benefits of family involvement, and access problems influenced decisions to exclude veterans or refuse to participate. Treatment was associated with decreased veteran anger expression (p≤.01) and increased social support and occupational activity (p≤.05), with effect sizes ranging from .6 to 1.0. Caregivers reported decreased burden (p≤.05) and increased empowerment (p≤.01). CONCLUSIONS: The results supported implementation of a randomized controlled trial, building in education at the provider and family level.

Multifamily group treatment for veterans with traumatic brain injury: what is the value to participants?

OBJECTIVE: This study evaluated the feasibility, acceptability, and helpfulness of implementation of multifamily group treatment for traumatic brain injury (TBI) among veterans who sustained a TBI during the wars in Iraq and Afghanistan and their families or caregivers. METHODS: Veterans and their family members who participated in an open clinical trial (August 2010-March 2011) of multifamily psychoeducation for TBI at two Veterans Affairs medical centers were invited to one of three focus groups. Participants were asked about problems experienced before and during the intervention, aspects of treatment that were helpful, and improvements that would facilitate effective implementation of multifamily group treatment for TBI. Postintervention focus group transcripts were analyzed by utilizing qualitative content analysis. RESULTS: Participants included eight veterans with TBI and eight family members. Five themes emerged: exploring common struggles and reducing isolation, building skills to cope with TBI and related problems, restoring relationships through communication and understanding, increasing understanding of the interconnection between TBI and posttraumatic stress disorder, and improving the multifamily group experience and increasing treatment engagement of veterans and families. Veterans and family members found multifamily group treatment for TBI highly acceptable and offered recommendations to improve and increase access to the program. CONCLUSIONS: The results supported the feasibility and acceptability of multifamily group treatment for TBI. Specific recommendations to improve this psychoeducational intervention and its implementation are offered.

Adapting the multifamily group model for treating veterans with posttraumatic stress disorder.

The Department of Veterans Affairs (VA) health care system's leadership has endorsed family involvement in veterans' mental health care as an important component of treatment. Both veterans and families describe family participation as highly desirable, and research has documented that having healthy social support is a strong protective factor for posttraumatic stress disorder (PTSD). Family psychoeducation has been shown to be effective in preventing relapse among severely mentally ill, and preliminary evidence suggests that family interventions for PTSD may improve veteran and family outcomes. The multifamily group (MFG) treatment model incorporates psychoeducation, communication training, and problem-solving skill building, and it increases social support through its group format. This article describes the rationale for further adaptation of the MFG model for PTSD, and it reviews issues related to its implementation as a promising adjunctive treatment as part of the continuum of PTSD services available in VA.

In our own voice-family companion: reducing self-stigma of family members of persons with serious mental illness.

OBJECTIVE: This article reports preliminary findings from a novel, family peer-based intervention designed to reduce self-stigma among family members of people with serious mental illness. METHODS: A total of 158 primary caregivers of patients with schizophrenia were recruited from a large urban mental health facility (93 caregivers) or from a family and consumer advocacy organization (65 caregivers). Caregivers (N=122) who reported they perceived at least a moderate level of mental illness-related stigma were evaluated on measures of self-stigma, withdrawal, secrecy, anxiety, and social comparison and randomly assigned to receive one of two, one-session group interventions: a peer-led intervention (In Our Own Voice-Family Companion [IOOV-FC]) designed to stimulate group discussion or a clinician-led family education session, which delivered information about mental illness in a structured, didactic format. IOOV-FC consisted of playing a videotape of family members who describe their experiences coping with stigma, which was followed by a discussion led by two family peers who modeled sharing their own experiences and facilitated group sharing. RESULTS: Of 24 family members and ten consumers, 96% rated the videotape above a predetermined acceptability threshold on a 19-item scale assessing cultural sensitivity, respect for different stakeholders, relevance of content, and technical quality (α=.92). Caregivers receiving IOOV-FC with low to moderate pretreatment anxiety reported a substantial reduction in self-stigma (effect size=.50) relative to those receiving clinician-led family education (p=.017) as well as significant reductions in secrecy (p=.031). CONCLUSIONS: Peer-led group interventions may be more effective in reducing family self-stigma than clinician-led education, at least for persons reporting experiencing low to moderate anxiety levels on a standard questionnaire

Family-focused treatment for caregivers of patients with bipolar disorder.

OBJECTIVES: Family members of patients with bipolar disorder experience high rates of subjective and objective burden which place them at risk for adverse physical health and mental health outcomes. We present preliminary efficacy data from a novel variation of Family Focused Treatment [Miklowitz DJ. Bipolar Disorder: A Family-Focused Treatment Approach (2(nd) ed.). New York: The Guilford Press, 2008] that aimed to reduce symptoms of bipolar disorder by working with caregivers to enhance illness management skills and self-care. METHODS: The primary family caregivers of 46 patients with bipolar I (n = 40) or II (n = 6) disorder, diagnosed by the Structured Clinical Interview for DSM-IV Axis I Disorders, were assigned randomly to receive either: (i) a 12-15-session family-focused, cognitive-behavioral intervention designed to provide the caregiver with skills for managing the relative's illness, attaining self-care goals, and reducing strain, depression, and health risk behavior [Family-Focused Treatment-Health Promoting Intervention (FFT-HPI)]; or (ii) an 8- to 12-session health education (HE) intervention delivered via videotapes. We assessed patients pre- and post-treatment on levels of depression and mania and caregivers on levels of burden, health behavior, and coping. RESULTS: Randomization to FFT-HPI was associated with significant decreases in caregiver depressive symptoms and health risk behavior. Greater reductions in depressive symptoms among patients were also observed in the FFT-HPI group. Reduction in patients' depression was partially mediated by reductions in caregivers' depression levels. Decreases in caregivers' depression were partially mediated by reductions in caregivers' levels of avoidance coping. CONCLUSIONS: Families coping with bipolar disorder may benefit from family interventions as a result of changes in the caregivers' ability to manage stress and regulate their moods, even when the patient is not available for treatment.

Impact of antipsychotic medication on family burden in schizophrenia: longitudinal results of CATIE trial.

BACKGROUND: This study evaluated the effectiveness of first- and second-generation antipsychotics in reducing family burden associated with schizophrenia. METHODS: The family caregivers of 623 SCID-diagnosed patients enrolled in the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) randomly assigned to a first-generation antipsychotic (perphenazine) or one of four second-generation drugs (olanzapine, quetiapine, risperidone or ziprasidone) were interviewed about resources provided and stresses experienced at baseline and followed for 18 months. Patient symptoms, side effects and service use were assessed as well. Hierarchical regression analyses evaluated the effect of treatment assignment on four burden factors: problem behavior, resource demands and disruption, impairment in activities of daily living and patient helpfulness. Intention-to-treat analyses with all available observations classified based on initial treatment assignment, including observations after medications changed were followed by secondary analyses excluding observations after the first medication change, i.e. only considering initial medication. RESULTS: Despite significant reductions on the problem behavior and resource demands/disruption factors, there were no significant differences between perphenazine and any of the second-generation medications. When only initial treatment period observations were included, patients were perceived as more helpful when medicated with perphenazine as compared to risperidone. In comparisons between second-generation drugs, patients on quetiapine were perceived as more helpful than those on risperidone (p=0.004). CONCLUSION: In this 18-month randomized trial, there was no evidence of superiority of second-generation antipsychotics in relieving family burden.

Suicidal ideation and depressive symptoms among bipolar patients as predictors of the health and well-being of caregivers.

OBJECTIVES: Few studies have addressed the physical and mental health effects of caring for a family member with bipolar disorder. This study examined whether caregivers' health is associated with changes in suicidal ideation and depressive symptoms among bipolar patients observed over one year. METHODS: Patients (N = 500) participating in the Systematic Treatment Enhancement Program for Bipolar Disorder and their primary caregivers (N = 500, including 188 parental and 182 spousal caregivers) were evaluated for up to one year as part of a naturalistic observational study. Caregivers' perceptions of their own physical health were evaluated using the general health scale from the Medical Outcomes Study 36-item Short-Form Health Survey. Caregivers' depression was evaluated using the Center for Epidemiological Studies of Depression Scale. RESULTS: Caregivers of patients who had increasing suicidal ideation over time reported worsening health over time compared to caregivers of patients whose suicidal ideation decreased or stayed the same. Caregivers of patients who had more suicidal ideation and depressive symptoms reported more depressed mood over a one-year reporting period than caregivers of patients with less suicidal ideation or depression. The pattern of findings was consistent across parent caregivers and spousal caregivers. CONCLUSIONS: Caregivers, rightly concerned about patients becoming suicidal or depressed, may try to care for the patient at the expense of their own health and well-being. Treatments that focus on the health of caregivers must be developed and tested.

Caregiver burden and health in bipolar disorder: a cluster analytic approach.

To identify caregivers at risk for adverse health effects associated with caregiving, the stress, coping, health and service use of 500 primary caregivers of patients with bipolar disorder were assessed at baseline, 6, and 12 months. K-means cluster analysis and ANOVA identified and characterized groups with differing baseline stress/coping profiles. Mixed effects models examined the effects of cluster, time, and covariates on health outcomes. Three groups were identified. Burdened caregivers had higher burden and avoidance coping levels, and lower mastery and social support than effective and stigmatized caregivers; stigmatized caregivers reported the highest perceived stigma (p < 0.05). Effective and stigmatized groups had better health outcomes and less service use than the burdened group over time; stigmatized caregivers had poorer self-care than effective caregivers. Cluster analysis is a promising method for identifying subgroups of caregivers with different stress and coping profiles associated with different health-related outcomes.

The family forum: directions for the implementation of family psychoeducation for severe mental illness.

It is well documented that family psychoeducation decreases relapse rates of individuals with schizophrenia. Despite the evidence, surveys indicate that families have minimal contact with their relative's treatment team, let alone participate in the evidence-based practice of family psychoeducation. The Department of Veterans Affairs (VA) sponsored a conference, the Family Forum, to assess the state of the art regarding family psychoeducation and to form a consensus regarding the next steps to increase family involvement. The forum reached consensus on these issues: family psychoeducation treatment models should be optimized by efforts to identify the factors mediating their success in order to maximize dissemination; leadership support, training in family psychoeducation models for managers and clinicians, and adequate resources are necessary to successfully implement family psychoeducation; because family psychoeducation may not be appropriate, indicated, or acceptable for all families, additional complementary strategies are needed that involve families in the mental health care of the patient; and work is required to develop and validate instruments that appropriately assess the intervention process and consumer and family outcomes. A treatment heuristic for working with families of persons with severe mental illness is also offered and provides a match of interventions at varying levels of intensity, tailored to family and consumer needs and circumstances. The article describes opportunities for the research and clinical communities to expand the proportion of families served.

Association of symptomatology and cognitive deficits to functional capacity in schizophrenia.

PURPOSE: This study aimed to evaluate the association of positive and negative symptoms, as well as of neurocognition to functional status in patients with schizophrenia. Participants were 309 veterans with DSM-IV-diagnosed schizophrenia or schizoaffective disorder who were enrolled in a 12-month double-blind clinical trial and randomized to receive either 5 to 20 mg/d of oral olanzapine or haloperidol. Patients were assessed at study entry and at 3, 6 and 12-months on the PANSS and measures of verbal memory, verbal fluency, fine motor coordination, visual sequencing/set shifting, and conceptual reasoning. Functional status was evaluated by the Heinrichs-Carpenter Quality of Life Scale (QLS) and by days of employment in the past 30. Hierarchical regression models examined the association of functional status with symptomatology and three neurocognitive factors (motor skills, memory and card sorting), controlling for demographics and visit number. A mixed effects model was used to adjust for repeated observations from the same subjects. RESULTS: The PANSS explained 16% additional variance in QLS total score after accounting for demographics and visit number (p<.001), while the neurocognitive factors explained only 4% additional variance beyond the effect of symptoms. When neurocognition was entered before symptoms, it explained an additional 8% of the variance on the QLS total score, while the PANSS explained an additional 12% over and above neurocognition. CONCLUSIONS: These findings suggest that symptoms may pose an equal or greater impediment to functional capacity independent of neurocognition, at least in younger non-institutionalized people with schizophrenia.

Current suicide ideation and prior suicide attempts of bipolar patients as influences on caregiver burden.

We examined whether caregivers of bipolar patients reporting current suicidal ideation and/or a history of a suicide attempt reported higher levels of burden and/or poorer health compared to caregivers of patients without these suicidality indices. In a cross-sectional design, caregivers (N = 480) associated with (a) patients with current suicidal ideation or (b) patients with a positive lifetime history of at least one suicide attempt, reported lower general health scores than caregivers associated with patients with neither of these indices. Parents of patients with at least one lifetime attempt reported more burden secondary to role dysfunction than spouses. Levels of depression in caregivers varied with whether the caregiver was a spouse or a parent, and whether patients had a history of suicide attempts, current suicidal ideation, or both.

Perceived stigma and depression among caregivers of patients with bipolar disorder.

This study investigates the associations between perceived stigma, depressive symptoms and coping among caregivers of people with bipolar disorder. Caregivers of 500 people with DSM-IV bipolar disorder responded to measures of these constructs at study entry. Patients' clinical and functional status were evaluated within 30 days of the caregiver assessment. Perceived stigma was positively associated with caregiver depressive symptoms, controlling for patient status and socio-demographic factors. Social support and avoidance coping accounted for 63% of the relationship between caregiver stigma and depression. Results suggest that caregivers' perceptions of stigma may negatively affect their mental health by reducing their coping effectiveness.

Prevalence and correlates of burden among caregivers of patients with bipolar disorder enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder.

OBJECTIVES: Caring for a relative with schizophrenia or dementia is associated with reports of high caregiver burden, symptoms of depression, poor physical health, negligence of the caregiver's own health needs, elevated health service use, low use of social supports, and financial strain. This study presents the design and preliminary data on the costs and consequences of caring for a relative or friend with bipolar disorder from the Family Experience Study, a longitudinal study of the primary caregivers to 500 patients enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder. METHODS: Subjects were primary caregivers of 500 patients with bipolar disorder diagnosed by the Mini International Neuropsychiatric Interview and the Affective Disorder Evaluation. Caregivers were evaluated within 1 month after patients entered Systematic Treatment Enhancement Program using measures of burden, coping, health/mental health, and use of resources and costs. RESULTS: Eighty-nine percent, 52%, and 61% of caregivers, respectively, experienced moderate or higher burden in relation to patient problem behaviors, role dysfunction, or disruption of household routine. High burden caregivers reported more physical health problems, depressive symptoms, health risk behavior and health service use, and less social support than less burden caregivers. They also provided more financial support to their bipolar relative. CONCLUSIONS: Burdens experienced by family caregivers of people with bipolar disorder are associated with problems in health, mental health, and cost. Psychosocial interventions targeting the strains of caregiving for a patient with bipolar disorder are needed.

Factors associated with stigma among caregivers of patients with bipolar disorder in the STEP-BD study.

OBJECTIVE: Little is known about the factors contributing to mental illness stigma among caregivers of people with bipolar disorder. METHODS: A total of 500 caregivers of patients participating in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study were interviewed in a cross-sectional design on measures of stigma, mood, burden, and coping. Relatives and friends with bipolar disorder were assessed on measures of diagnosis and clinical status, determined by a days-well measure derived from psychiatrist ratings of DSM-IV episode status. Because patients' clinical status varied widely, separate models were run for patients who were euthymic for at least three-fourths of the past year (well group) and for those who met criteria for an affective episode for at least one-fourth of the previous year (unwell group). Stepwise multiple regression was used to identify patient, illness, and caregiver characteristics associated with caregiver stigma. RESULTS: In the unwell group, greater mental illness stigma was associated with bipolar I (versus II) disorder, less social support for the caregiver, fewer caregiver social interactions, and being a caregiver of Hispanic descent. In the well group, greater stigma was associated with being a caregiver who is the adult child of a parent with bipolar disorder, who has a college education, who has fewer social interactions, and who cares for a female bipolar patient. CONCLUSIONS: Mental illness stigma was found to be prevalent among caregivers of persons with bipolar disorder who have active symptoms as well as for caregivers of those who have remitted symptoms. Stigma is typically associated with factors identifying patients as "different" during symptomatic periods. Research is needed to understand how the stigma experienced by caregivers during stable phases of illness differs from the stigma experienced during patients' illness states.

Modeling costs and burden of informal caregiving for persons with bipolar disorder.

BACKGROUND: Informal caregiving contributes significantly to the health and well being of chronically ill persons. While a vast literature demonstrates this connection, the cost and financial burden of informal caregiving has received considerably less research attention, especially as it-pertains to bipolar disorder. AIMS OF THE STUDY: This paper develops an integrated burden model of informal caregiving, which is contrasted with other more traditional models of caregiving costs, and then uses these models to estimate the financial burden of bipolar disorder. The "goodness" of these various models is measured in terms of their correlation with measures of objective and subjective burden for caregivers of persons with bipolar disorder. METHODS: The study was an ancillary protocol to the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) and included primary caregivers of 500 people with bipolar disorder. Approximately 96% (n=486) caregivers participated in the study. Caregivers were interviewed at baseline, and six and 12 months after an initial interview. The semi-structured interview included questions on (i) subjective distress; (ii) the types of support and services; (iii) caregiver use of formal and informal services and support; and (iv) contributions received from the relative with bipolar over the past month. RESULTS: The correlations between financial burden and psychological burden measures were positive and statistically significant in cases where all resource costs were measured but adjusted for reciprocated giving and customary generosity (the integrated model). The strength of correlations was greater when time is valued at its opportunity cost (and not imputed) and the caregiving costs based on this valuation approach were logarithmically transformed. DISCUSSION: The magnitude of the correlations is consistent with the notion that caregiver burden is a coherent construct with multiple different dimensions. Financial burden appears to be a unique dimension that is significantly intercorrelated with psychological measures but is not redundant with them. The robustness of these findings need to be tested with larger samples and across caregiver illness groups. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Caregiving is likely to have health and stress-related consequences that increase caregiving costs. Understanding which costs are associated with feelings of burden can be used to inform the design of interventions to minimize the stressful or burdensome aspects of caregiving. Giving back reduces the magnitude of caregiving costs and the sense of psychological burden. Interventions that develop the potential to "give back" are likely to be beneficial for both the caregiver and the care receiver as it increases reciprocity and decreases dependency. IMPLICATIONS FOR FURTHER RESEARCH: Caution is needed in estimating the costs of informal caregiving needs as many costs are possible but their relationship to burden varies in strength and significance. Assumptions related to what is given and received and how this relates to expected patterns of giving and receiving in measuring and determining financial burden and costs are particularly important, as is the valuation of time.