Longitudinal impact of caregiver transition and family caregiving on psychiatric symptoms and psychosocial functioning among persons with schizophrenia in rural China.

This study examines the 21-year longitudinal impacts and predictive effects of family caregiver transition and the presence of family caregiving on the clinical status of persons with schizophrenia (PwSs) in a rural area of China. Using panel data derived from the Chengdu Mental Health Project (CMHP), 250 dyads of PwSs and their family caregivers were investigated in 1994 and 2015. The Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning (GAF) were utilized. The generalized linear model (GLM) approach was used. The results of this study showed that more severe symptoms in PwSs were found to be significantly predicted by older age and nonmarried status at baseline. Compared with "spousal caregiving in two waves," the PANSS score was significantly higher in the "transition into sibling caregiving" group. A higher degree of psychosocial functioning was found to be significantly predicted by marital status, shorter duration of illness, and better mental status. Compared with "spousal caregiving in two waves," the GAF score was significantly lower in the "transition into parental caregiving" group. The presence of family caregiving was not a significant predictor of the severity of symptoms or psychosocial functioning in the PwSs. In conclusion, this study shows the 21-year predictive effects of family caregiver transition on the mental status of PwSs but not the presence of family caregiving. Psychosocial interventions and specific guidance should be provided to family caregivers to enhance their quality of caregiving and improve the prognosis of PwSs during long periods of home care.

En este estudio se analizan los efectos longitudinales a 21 años y los efectos pronósticos de la transición de los cuidadores familiares y la presencia de cuidado familiar en el estado clínico de las personas con esquizofrenia en un área rural de China. Utilizando datos de panel extraídos del Proyecto de salud mental de Chengdu (Chengdu Mental Health Project, CMHP), se investigaron 250 díadas de personas con esquizofrenia y sus cuidadores familiares en 1994 y 2015. Se utilizó la Escala de síndrome positivo y negativo (Positive and Negative Syndrome Scale, PANSS) y la Evaluación global del funcionamiento (Global Assessment of Functioning, GAF). También se utilizó el método de modelo lineal generalizado. Los resultados de este estudio demostraron que los síntomas más intensos en las personas con esquizofrenia fueron pronosticados principalmente por la edad avanzada y el estado de soltería en el momento basal. En comparación con el grupo de "cuidado de los cónyuges en dos intervalos", el puntaje de la PANSS fue considerablemente más alto en el grupo de "transición al cuidado de los hermanos". Se descubrió que principalmente el estado civil, la duración más corta de la enfermedad y un mejor estado mental pronosticaron un grado más alto de funcionamiento psicosocial. En comparación con el grupo de "cuidado de los cónyuges en dos intervalos", el puntaje de la GAF fue considerablemente más bajo en el grupo de "transición al cuidado de los padres". La presencia de cuidado familiar no fue un factor pronóstico importante de la intensidad de los síntomas ni del funcionamiento psicosocial en las personas con esquizofrenia. En resumen, en este estudio se muestran los efectos pronósticos a 21 años de la transición de los cuidadores familiares en el estado mental de las personas con esquizofrenia, pero no la presencia de cuidado familiar. Deben ofrecerse intervenciones psicosociales y orientación específica a los cuidadores familiares para mejorar su calidad de cuidado y mejorar el pronóstico de las personas con esquizofrenia durante los periodos prolongados de cuidado en el hogar.

[Influence of the companion in Primary Care consultations on communication skills and interview time]. / Influencia del acompañante en las consultas de Atención Primaria sobre las habilidades en comunicación y el tiempo de entrevista.

OBJETIVES: To know the influence of the companion in triadic clinical encounter on the quality of doctor-patient communication and the duration of the interview. DESIGN: Cross-sectional descriptive study. LOCATION: 10 Primary Care Centers. PARTICIPANTS: Resident doctors of Family and Community Medicine. INTERVENTIONS: Peer review of video recordings of clinical demand consultations. MAIN MEASUREMENTS: CICAA-2 questionnaire to assess communication skills (improvable, acceptable or adequate); age and sex, reasons for consultation and duration of the interview. Bivariate and multivariate analyses. Ethical authorization, oral informed consent and custody of the video recordings. RESULTS: 73 RD (53.8% women, 32.9±7.7 years) participated with 260 interviews (60.3% women and 2.1±1.0 clinical demands). 27.7% of consultations with a companion (female sex 65.3%). The mean duration of the interviews was 8.5±4.0min. Clinical encounters lasted longer when a companion attended (2.7±0.5min more; p<.001 Student t) and with a greater number of clinical demands (40% with ≥3 reasons, p=0.048 X2). The mean value of the total score of the CICAA-2 scale (46.9±16.5; difference 4.6±2.3) and Task 2 (39.3±15.8 with difference 4.4±2.2) were higher when companion was present (p<.05 Student t). The model obtained with logistic regression shows a longer duration of the consultation with a companion (OR 1.2; CI [1.1-1.3]) and possibly a better score in Task 2 communication skills (OR 1.02; CI [0.99-1.1]). CONCLUSIONS: Triadic communications challenge the clinician's communication skills, improving their abilities to identify and understand patient problems, albeit at the cost of a greater investment of time.

Family Dynamics in Dementia Caregiving: Development and Validation of the Interpersonal Triggers of Guilt in Dementia Caregiving Questionnaire (ITGDCQ).

The objective was to develop the Interpersonal Triggers of Guilt in Dementia Caregiving Questionnaire (ITGDCQ). An emotion frequently experienced by caregivers is guilt. However, the studies analyzing potential factors that generate guilt are scarce. Guilt may be generated through interpersonal interactions. A total of 201 dementia caregivers were evaluated for frequency of leisure, guilt, anxiety, depression, and a pool of items measuring the frequency, and guilt was derived from different behaviors performed by the care recipient (ITGDCQ-CR) and other relatives (ITGDCQ-OR). Exploratory factor analysis of the ITGDCQ-CR showed a two-factor solution, explaining 56.24% of the variance. The ITGDCQ-OR subscale also showed two factors, explaining 63.24% of the variance. All the factors had acceptable to good reliability indexes. Positive associations were found between both subscales and depression, anxiety, guilt, and stress associated with CR's behavioral problems. ITGDCQ-CR was negatively correlated with frequency of leisure. The interpersonal dynamics assessed with the ITGDCQ generated other emotions such as anger or sadness. Through structural equation modeling, 28% of the variance of caregivers' distress was explained by the assessed variables, including a significant contribution of the interpersonal dynamics assessed with the ITGDCQ. The results provide preliminary support for the use of the ITGDCQ as a valid and reliable measure of care recipients' or other relatives' factors that trigger or facilitate the experience of guilt in the caregivers. The association between these factors and caregiver distress suggests potential clinical implications for the findings.

Interventions for Family Members and Carers of Patients with Borderline Personality Disorder: A Systematic Review.

Carers of patients with borderline personality disorder (BPD) experience high levels of distress. Several studies have been carried out on interventions designed to decrease their burden. However, the evidence from these studies has not been summarized. The objective of this work is to explore the clinical utility of interventions developed for family members of patients with BPD. A systematic review was conducted following the PRISMA guidelines (registration number CRD42018107318), including psychological interventions focused on relatives of patients with BPD. The following databases were used: PsycINFO, PubMed, EBSCOhost, and Web of Science. Two independent researchers reviewed the studies to determine whether the eligibility criteria were met. A total of 2,303 abstracts were identified. After duplicates had been removed, 1,746 studies were screened. Finally, 433 full-text articles were reviewed, yielding 11 studies that satisfied the inclusion criteria. Results show that these interventions with different clinical formats and settings are effective. The quality of the included studies varies, and the empirical support for these programs is still preliminary. The results help to establish a general framework for interventions specifically developed for family members of patients with BPD, but additional efforts should be made to improve the methodological quality of this field of research and more solidly determine the utility of these interventions. Given the paucity of data so far, this information may open up new lines of research to improve the effectiveness of future programs for carers of patients with BPD and help to reduce their burden.

Los familiares de pacientes con trastorno límite de la personalidad (TLP) experimentan elevados niveles de estrés. Se han llevado a cabo varios estudios sobre intervenciones diseñadas para disminuir su carga. Sin embargo, los datos obtenidos de estos estudios no se han expuesto. El objetivo de este trabajo es explorar la utilidad clínica de las intervenciones desarrolladas para los familiares de los pacientes con TLP. Se realizó una revisión sistemática siguiendo las directrices de PRISMA (número de registro CRD42018107318), que incluyó intervenciones psicológicas centradas en los familiares de los pacientes con TLP. Se utilizaron las siguientes bases de datos: PsycINFO, PubMed, EBSCOhost, y Web of Science. Dos investigadores independientes revisaron los estudios para determinar si se cumplían los criterios de elegibilidad. Se identificaron un total de 2303 resúmenes. Después de extraer los duplicados, se evaluaron 1746 estudios. Finalmente, se revisaron 433 artículos de texto completo, lo que dio lugar a 11 estudios que cumplían los criterios de inclusión. Los resultados demuestran que estas intervenciones con diferentes formatos y orientaciones clínicas son eficaces. La calidad de los estudios incluidos varía, y el apoyo empírico para estos programas es todavía preliminar. Los resultados contribuyen a establecer un marco general para las intervenciones desarrolladas específicamente para los familiares de los pacientes con TLP, pero se deberían realizar esfuerzos adicionales para mejorar la calidad metodológica de este campo de investigación y determinar con mayor solidez la utilidad de estas intervenciones. Dada la escasez de datos hasta el momento, esta información puede abrir nuevas líneas de investigación para mejorar la eficacia de los futuros programas para los cuidadores de los pacientes con TLP y ayudar a reducir su carga.

Risk and Resiliency Factors Related to Dementia Caregiver Mental Health.

Prevalence rates for dementia are expected to rise exponentially as the elderly population rises. With this comes a corresponding increase in the number of family members who will become dementia caregivers. Caregivers of people with dementia often experience a deterioration in mental health. Identifying factors that relate to caregiver mental health is necessary to develop appropriate interventions. The current study explored how family functioning (measured with a latent variable that includes family cohesion, family balance, and family communication), caregiver expressed emotion (EE), and patient symptom severity related to caregiver mental health (measured with a latent variable that includes depression, anxiety, and stress). Participants included 107 dementia caregivers. The following specific hypotheses were tested: lower levels of both (1) EE and (2) patient symptom severity, and (3) higher levels of family functioning would be related to better caregiver mental health. Results produced a well-fitting model: X2 (18) = 14.858, p = .672; CFI = 1.00; RMSEA = .00; SRMR = .037. Moreover, results indicated that better family functioning (Ɣ = -3.54, SE = 1.34, p = .008), lower levels of caregiver EE (ß = .36, SE = 0.07, p < .01), and higher patient symptom severity (ß = -3.03, SE = 0.88, p = .001) were related to better caregiver mental health. Results from this study suggest that efforts to bolster family functioning (i.e., enhance communication, promote cohesion, encourage flexibility) could help improve caregiver mental health.

Se espera que los índices de prevalencia de la demencia aumenten exponencialmente a medida que se incremente la población de personas mayores. Esto trae aparejado un aumento correspondiente del número de familiares que se convertirán en cuidadores de personas con demencia. Los cuidadores de personas con demencia frecuentemente sufren un deterioro de la salud mental. Por eso, es necesario identificar los factores relacionados con la salud mental de los cuidadores para desarrollar intervenciones adecuadas. El presente estudio analizó cómo el funcionamiento familiar (medido con una variable latente que incluye cohesión familiar, equilibrio familiar y comunicación familiar), la emoción expresada por los cuidadores y la gravedad de los síntomas de los pacientes se relacionaron con la salud mental de los cuidadores (medida con una variable latente que incluye depresión, ansiedad y estrés). Los participantes fueron 107 cuidadores de personas con demencia. Se evaluaron las siguientes hipótesis específicas: los niveles bajos de 1) emoción expresada y 2) gravedad de los síntomas de los pacientes, y 3) los niveles más altos de funcionamiento familiar estarían relacionados con una mejor salud mental de los cuidadores. Los resultados generaron un modelo con buen ajuste: X2 (18) = 14.858, p = .672; CFI = 1.00; RMSEA = .00; SRMR = .037. Además, los resultados indicaron que un mejor funcionamiento familiar (Ɣ = -3.54, SE = .1.34, p = .008), niveles más bajos de emoción expresada por los cuidadores (ß = .36, SE = .07, p<.01) y una mayor gravedad de los síntomas de los pacientes (ß = -3.03, SE = .88, p = .001) estuvieron relacionados con una mejor salud mental de los cuidadores. Los resultados de este estudio sugieren que los esfuerzos para reafirmar el funcionamiento familiar (p. ej.: mejorar la comunicación, promover la cohesión, estimular la flexibilidad) podrían contribuir a mejorar la salud mental de los cuidadores.

Development and validation of the Attachment Relationship Inventory-Caregiver Perception 2-5 years (ARI-CP 2-5): Psychometric structure, external validity, and norms.

There is a lack of instruments assessing child-caregiver attachment relationships in early childhood to be used in attachment-based practice, in particular from a caregiver's perception, which is an important factor of clinical importance to take into account in parenting interventions targeting young children. Therefore, the 48-item Attachment Relationship Inventory-Caregiver Perception 2-5 years (ARI-CP 2-5) was developed. Survey data of 446 caregivers of 2- to 5-year-old children were collected, and a subsample of 83 caregivers participated in an observation study. Confirmatory factor analysis confirmed a four-factor structure of secure, avoidant, ambivalent, and disorganized attachment relationship. Indications of configural, metric, and scalar invariance were found for caregivers' and children's sex, children's age, and population (clinical vs. general population). The four scales showed sufficient internal consistency and significant associations with children's psychopathology, caregivers' general attachment representations, caregivers' mind-mindedness, and population type. Moreover, preliminary evidence for convergent validity with observational attachment measures was found. It is concluded that the ARI-CP 2-5 is a valid instrument that can be used as part of the screening and assessment of insecure attachment relationships.

Hacen falta instrumentos que evalúen las relaciones de afectividad niño-cuidador en la temprana niñez para ser usados en la práctica que se basa en la afectividad, en particular desde la perspectiva del cuidador, lo cual es un factor clave de importancia clínica para tomar en cuenta en las intervenciones de crianza que se enfocan en niños pequeños. Por tanto, se desarrolló el Inventario de la Relación Afectiva - Percepción del Cuidador 2-5 años, que consta de 48 aspectos (ARI-CP 2-5). Se recogió información de encuesta de 446 cuidadores de niños de 2 a 5 años de edad, y un subgrupo muestra de 83 cuidadores participó en un estudio de observación. Los análisis de factores confirmatorios corroboraron una estructura de cuatro factores de la relación de afectividad que es segura, la que evita, la ambivalente y la desorganizada. Se encontraron indicaciones de invariabilidad en el aspecto configuracional, métrico y de escala en cuanto al género sexual de los cuidadores y del niño, la edad del niño, y la población (clínica y general). Las cuatro escalas mostraron una suficiente consistencia interna y asociaciones significativas con la sicopatología de los niños, las representaciones generales de afectividad del cuidador, la conciencia mental de los cuidadores, así como el tipo de población. Es más, se encontró una evidencia preliminar para la validez convergente con las medidas de afectividad de observación. Se concluye con que el ARI-CP 2-5 es un instrumento válido que puede usarse como parte de la detección y evaluación de las relaciones de afectividad inseguras.

Il y a un manque d'instruments évaluant les relations d'attachement enfant-aidant naturel dans la petite enfance pouvant être utilisés dans une pratique basée sur l'attachement, en particulier sur la perception de l'aidant naturel, qui est un facteur important de l'importance clinique à prendre en compte dans les interventions de parentages ciblant les jeunes enfants. Par conséquent l'Inventaire de 48 articles de la Relation d'Attachement - Perception de l'Aidant Naturel 2-5 ans (abrégé en anglais ARI-CP 2-5) a été développé. Les données de sondage de 446 aidants naturels d'enfants de 2 à 5 ans ont été recueillies et un sous-échantillon de 83 aidants naturels ont participé à une étude d'observation. Une analyse factorielle confirmatoire a confirmé une structure à quatre facteurs de la relation d'attachement sécure, évitant, ambivalent et désorganisé. Des indications d'invariance configurale, métrique et scalaire ont été trouvées pour le sexe des aidants naturels et des enfants, l'âge des enfants, et la population (clinique par rapport à population générale). Les quatre échelles ont démontré une cohérence interne suffisante et des associations importantes avec la psychopathologie des enfants, les représentations de l'attachement générale des aidants naturels, l'esprit-qualité mentale et le type de population. De plus une preuve préliminaire de validité convergente ave les mesures observationnelles d'attachement a été trouvée. Nous concluons que l'ARI-CP 205 est un instrument valide qui peut être utilisé pour le dépistage et l'évaluation de relations d'attachement insécures.

[The care in the prevention of falls in elderly people: Meta-summary of qualitative articles]. / El cuidado en la prevención de caídas en personas mayores: metaresumen de artículos cualitativos.

OBJECTIVE: To summarize the qualitative evidence on the role of care providers in the prevention of falls of persons over 65 years of age in centres and in the community. DESIGN: Meta-summary of qualitative evidence following the aggregation method. DATA SOURCES: Extensive manual search of 16 databases (CINAHL, Pubmed/Medline, Embase, PsycInfo, Cochrane Library, PeDRO, Opengrey (Reports), Cuiden, Cuidatge, Enfispo, Medes, Lilacs, Teseo, Dissertation and Thesis Global and Ibecs), in English, French, Spanish and Portuguese; no time limit. SELECTION OF STUDIES: Selection and blind critical appraisal by pairs. A first relevance and relevance screening and a second critical appraisal screening were carried out. A total of 4170 articles were located; 41 qualitative articles were critically appraised and 31 were selected. DATA EXTRACTION: Data regarding author, year, study design, location, participants (number, age, sex and occupation), study methods and findings were extracted. RESULTS: The analysis revealed four major themes: precipitating factors, preventive models, feelings and decision-making process. It also highlights the difficult act of ethical balance, the role of the institution in prevention and the fragmentation of care, as keys to successful implementation. CONCLUSIONS: The findings show the complexity of fall prevention and the need to incorporate care providers' opinions in preventive models.

[Evaluation of the effectiveness of an intervention program in family caregivers of dependent persons, in the primary health care system]. / Evaluación de la efectividad de un programa de intervención en cuidadores no profesionales de personas dependientes en el ámbito de la atención primaria.

OBJECTIVE: Evaluate the effectiveness of an intervention to family caregivers. DESIGN: Quasi-experimental study of type before/after, without control group. SETTING: Primary care; 5 primary care centers of Castelló city. PERIOD: Between the month of January 2018 and the month of January 2019. PARTICIPANTS: 72 family caregivers, participants in a specific intervention recently implemented in the Department de Salut de Castelló. INTERVENTION: Training to family caregivers, seeking to improve knowledge of dependent care, and provide support. Ten group sessions of 120minutes. PRINCIPAL MEASUREMENTS: Descriptive of sociodemographic data. Comparison of the variables overload, low back pain, social support and health-related quality of life before-after the intervention. Variable response: caregiver overload. Bivariate and multivariate analysis. RESULTS: All family caregivers had baseline overload (59.93±14.71); 73.3% showed low back pain, with an average level of 5.13±2.56 and moderate disability (41.7%). 50% received little social support and a great impact on health-related quality of life, especially in terms of pain and anxiety. After the intervention, there was a significant improvement (P=.004) in social support, as well as positive descriptive changes in disability due to low back pain and health-related quality of life dimensions. No progress was found (P>.05) for the presence and level of low back pain, as well as overload levels. CONCLUSIONS: The resulting effective intervention to improve perceived social support. However, the low impact on other variables suggests reconsidering its contents, as well as encouraging new prospective studies that may offer more encouraging results.

[Need and use of assistive devices and architectural facilitators in a dependent population]. / Necesidad y uso de productos de apoyo y facilitadores arquitectónicos en población dependiente.

OBJECTIVE: To describe the use and perception of the need for assistive devices and identify their relationship with instruments to measure dependence and caregiver burden. DESIGN: Cross-sectional study. LOCATION: Primary Health Care in the southern area of Pontevedra. PARTICIPANTS: A total of 112 informal caregivers providing care to 125 dependent persons. KEY MEASUREMENTS: Through a personal interview, data was collected on the use and perception of the need for these devices. In addition, sociodemographic data and information on the time dedicated to daily care, caregiver burden, the Dependency Rating Scale, and the DEP-6D dependency indicator were obtained. A contrast mean was used to identify whether there are significant differences in these indicators, depending on whether or not they use the facilitator devices. A logistic regression was performed to identify those variables most associated with not having a need covered. RESULTS: More than half (60%: 95% CI; 50.9-68.7) of dependent persons have unmet needs for these devices. These needs are mainly associated with a low family income, a high degree of dependence, and better health of the caregiver; although in extreme situations of greater dependence and worse health of the caregiver these deficiencies are smoothed out. CONCLUSIONS: There is a strong association between the level of dependence and the use of these devices. However, there is a high percentage of the sample that do not have the products that they need, which are associated with the socioeconomic situation of the household as well as with the characteristics of the dependent person and the caregiver.

Relationship between Mental Health and Burden among Primary Caregivers of Outpatients with Schizophrenia.

There is growing recognition that caring for a patient with schizophrenia often results in high levels of perceived burden and poorer overall mental health for caregivers. A quantitative cross-sectional design and standardized instruments were used to collect data from 355 primary caregivers of adults in outpatient care with schizophrenia in China. Structural equation modeling was used to examine the association between caregiver burden and mental health among primary caregivers and whether this association is influenced by personality, coping style, and family functioning, based on a diathesis-stress perspective. Goodness-of-fit indices (χ2 /df = 1.406, GFI = 0.919, CFI = 0.957, etc.) confirmed that the modified model fit the data well. In line with the diathesis-stress model, and with this study's hypotheses, we found that caregiver burden was significantly related to mental health outcomes directly. The final model showed that personality traits, coping style, and family function influenced the relationship between caregiver burden and mental health. The neuroticism personality traits have a direct effect on caregiver burden and family functioning in this sample. Coping style had a direct effect on the caregiver burden, and family functioning had a direct effect on the caregiver burden. Our final model about primary caregivers can be applied clinically to predict mental health outcomes from caregiver burden.

Cada vez se reconce más que cuidar a un paciente con esquizofrenia generalmente resulta en niveles altos de sobrecarga percibida y en una peor salud mental general para los cuidadores. Se utilizó un diseño transversal cuantitativo e instrumentos estandarizados para recopilar datos de 355 cuidadores principales de adultos con esquizofrenia en atención extrahospitalaria en China. Se utilizaron modelos de ecuaciones estructurales para analizar la asociación de la sobrecarga del cuidador y la salud mental entre cuidadores principales, y si esta asociación está influenciada por la personalidad, el estilo de afrontamiento y el desempeño familiar sobre la base de una perspectiva diátesis-estrés. Los índices de bondad de ajuste (χ2 /df = 1.406, GFI = 0.919, CFI = 0.957, etc.) confirmaron que el modelo modificado se ajustó bien a los datos. De acuerdo con el modelo de diátesis-estrés y con las hipótesis de este estudio, descubrimos que la sobrecarga del cuidador estuvo considerablemente relacionada con las consecuencias en la salud mental directamente. El modelo definitivo demostró que los rasgos de la personalidad, el estilo de afrontamiento y el desempeño familiar influyeron en la relación entre la sobrecarga del cuidador y la salud mental. Los rasgos de personalidad de neuroticismo tienen un efecto directo en la sobrecarga del cuidador y el desempeño familiar en esta muestra. El estilo de afrontamiento tuvo un efecto directo en la sobrecarga del cuidador y el desempeño familiar tuvo un efecto directo en la sobrecarga del cuidador. Nuestro modelo definitivo acerca de los cuidadores principales puede aplicarse clínicamente para predecir las consecuencias de la sobrecarga del cuidador en su salud mental.

[To recuperate and preserve the relative: Family caregivers strategies to manage mental health crisis]. / Recuperar y conservar al familiar: estrategias de los familiares cuidadores para hacer frente a las crisis de salud mental.

AIM: To know and understand the strategies carried out by the relatives of people with mental health problems in the care of their sick relatives. DESIGN: Qualitative study SETTING: Mental Health Service (SESCAM) and Social Health Centres of Castilla-La Mancha region (Spain). PARTICIPANTS: Twenty-four adult family members who live and care for a family member who suffers a mental health crisis. The participants were contacted both through the health directorate of the area and a social health foundation. They were selected with purpose and by snowball sampling. METHOD: Twenty-two semi-structured were conducted and analysed according to the constructivist grounded theory procedures between January 2014 and February 2016. The theoretical sampling guided the obtaining of the data that ended with the saturation of the emerging categories. RESULTS: A person with a mental problem during a crisis becomes a stranger and is inaccessible to family members. In this situation the efforts are aimed at the recovery of the relative, to take them out of the unreason and to keep them in a day-to-day normality constructed for them. Thanks to this, the ill relative is integrated into family life. CONCLUSIONS: Family caregivers of people with mental problems struggle not to lose them in a crisis and to maintain family ties. Primary care professionals must give importance to these links, because it determines their care strategies during a crisis and the strategies to conserve the family member.

Stigma, Expressed Emotion, and Quality of Life in Caregivers of Individuals with Dementia.

Expressed emotion (EE) is a measure of a caregiver's critical and emotionally overinvolved (EOI; e.g., intrusive, self-sacrificing) attitudes and behaviors toward a person with a mental illness. Mounting evidence indicates that high levels of these critical and EOI attitudes and behaviors (collectively termed high EE) in family members are associated with a poorer course of illness for people with a range of disorders, including dementia (Nomura et al., 2005). However, less is known about factors that might trigger high EE and how high EE might impact dementia caregivers' own mental health. In this study we propose that caregivers who perceive stigma from their relative's illness may be more likely to be critical or intrusive (high EOI) toward their relative in an attempt to control symptomatic behaviors. We further hypothesized that high EE would partially mediate the link between stigma and quality of life (QoL) as there is some evidence that high EE is associated with poorer mental health in caregivers themselves (Safavi et al., 2015). In line with study hypotheses and using a sample of 106 dementia caregivers, we found that greater caregiver stigma was associated with both high EE (for criticism and EOI) and with poorer QoL. Mediational analyses further confirmed that high EE accounts for much of the association between stigma and poorer QoL. Study results suggest that addressing caregiver stigma in therapy could reduce levels of high EE and indirectly therefore improve caregiver QoL. Intervening directly to reduce high EE could also improve caregiver QoL.

[The first moments of the carer: The process of becoming a caregiver of a dependent elderly relative]. / Primeros momentos del cuidado: el proceso de convertirse en cuidador de un familiar mayor dependiente.

AIM: Describe the initial process through which people who imminently become caregivers of a dependent elderly relative. DESIGN: Qualitative study, for which its analysis has been directed by Grounded Theory principles. LOCATION: This study was conducted in the Health Districts of Jaén, during 2015 and 2016 at the community level. PARTICIPANTS AND/OR CONTEXTS: The recruitment was carried out by managers of the Health Centres of each Health District, who located the participants who met the inclusion criteria and invited them to participate in the study. METHOD: Eleven in-depth interviews were carried out, until saturation of information, on individuals who had been caring for an older relative with dependency for less than one year. RESULTS: Three phases have been described during this process. An initial phase of changes, in which the caregiver assumes new activities; a second phase full of emotions, in which the needs and consequences emerge in caregivers; and a third phase that emphasises acceptance as a coping strategy and uncertainty as an expectation of the future. DISCUSSION: The description of this process provides a comprehensive understanding of the experience of becoming a family caregiver, in order to help health professionals to adapt to the plans of care for this initial situation.

Neurocognitive Impairment: Addressing Couple and Family Challenges.

Conditions involving neurocognitive impairment pose enormous challenges to couples and families. However, research and practice tend to focus narrowly on immediate issues for individual caregivers and their dyadic relationship with the affected member. A broad family systems approach with attention to family processes over time is needed in training, practice, and research. In this paper, Rolland's Family Systems Illness model provides a guiding framework to consider the interaction of different psychosocial types of neurocognitive conditions and their evolution over time with individual, couple, and family life-course development. Discussion addresses key family and couple issues with mild-to-severe cognitive impairment and progressive dementias, including: communication, multigenerational legacies, threatened future neurocognitive disability, ambiguous loss, decisional capacity, reaching limits, placement decisions, issues for adult children and spousal caregivers, and the transformation of intimate bonds. Principles and guidelines are offered to help couples and families master complex challenges, deepen bonds, and forge positive pathways ahead.

Changes in Families' Caregiving Experiences through Involvement as Participants then Facilitators in a Family Peer-Education Program for Mental Disorders in Japan.

A family peer-education program for mental disorders was developed in Japan, similar to existing programs in the United States and Hong Kong. Families that serve as facilitators in such programs may enhance their caregiving processes and, thereby, their well-being. This study's aim was to describe how families' caregiving experiences change, beginning with the onset of a family member's mental illness, through their involvement in a family group or peer-education program as participants then facilitators. Thus, this study was conducted in a family peer-education program for mental disorders in Japan. Group interviews were conducted with 27 facilitators from seven program sites about their experiences before, during, and after becoming facilitators. Interview data were coded and categorized into five stages of caregiving processes: (1) withdrawing and suppressing negative experiences with difficulty and regret; (2) finding comfort through being listened to about negative experiences; (3) supporting participants' sharing as facilitators; (4) understanding and affirming oneself through repeated sharing of experiences; and (5) finding value and social roles in one's experiences. The third, fourth, and fifth stages were experienced by the facilitators. The value that the facilitators placed on their caregiving experiences changed from negative to positive, which participants regarded as helpful and supportive. We conclude that serving as facilitators may improve families' caregiving processes.

[Coping and subjective burden in primary caregivers of dependent elderly relatives in Andalusia, Spain]. / Afrontamiento y carga subjetiva en cuidadores primarios de adultos mayores dependientes de Andalucía, España.

PURPOSE: To analyse the relationship between the type of coping and subjective burden in caregivers of dependent elderly relatives in Andalusia (Spain). DESIGN: Cross-sectional study. LOCATION: Primary Health Care (autonomous community of Andalusia, Spain). PARTICIPANTS: A convenience sample of 198 primary caregivers of dependent elderly relatives. KEY MEASUREMENTS: Coping (Brief COPE), subjective burden (caregiver stress index), objective burden (functional capacity [Barthel Index], cognitive impairment [Pfeiffer Test], behavioural problems of the care recipient [Neuropsychiatric Inventory], and caregivers' dedication to caring), gender and kinship. RESULTS: Most caregivers were women (89.4%), daughters of the care recipient (57.1%), and shared home with him/her (69.7%). On controlling for objective burden, gender and kinship, it was found that subjective burden was positively associated with dysfunctional coping (ß=0.28; P<.001) and negatively with emotion-focused coping (ß=-0.25; P=.001), while no association was found with problem-focused coping. CONCLUSIONS: Dysfunctional coping may be a risk factor for subjective burden, and emotion-focused coping may be a protective factor for that subjective burden regardless of the objective burden, and gender and kinship of the caregivers.

[Cross-sectional study of informal caregiver burden and the determinants related to the care of dependent persons]. / Estudio observacional transversal de la sobrecarga en cuidadoras informales y los determinantes relacionados con la atención a las personas dependientes.

OBJECTIVE: To describe the burden of informal carers of dependent people and to identify related variables. DESIGN: Descriptive observational cross-sectional study. LOCATION: Primary Health Care in the southern area of Pontevedra. PARTICIPANTS: 97 caregivers of dependent persons. KEY MEASUREMENTS: We collected socioeconomic data and health conditions from caregivers and dependent persons, time spent on the daily care and caregiver burden (Zarit abbreviate) through a personal interview. Besides the description of the sample-including their burden level-, a contrast mean was used to identify characteristics that influenced in punctuation of Zarit scale. A logistic regression was used to analyse characteristics that increase the likelihood to experiment burden. RESULTS: 61.9% of caregivers are subject to intense burden. The item on the scale which contributes most to the caregiver burden is the lack of time for oneself, followed by the negative effects of interpersonal relationships. Contrast means shows that degree of relationship, number of care hours, caregiver health and aggressiveness of dependent persons produce significant differences in Zarit scale. Physic and psychological health of caregivers and aggressiveness of dependent persons is associated with the likelihood of developing caregiver burden. CONCLUSIONS: Informal caregivers of dependent persons show a high level of burden, both related to their characteristics and those of the dependent persons. Caregiver burden rethinks the need for public policies focused on dependence to adopt an integrative caregiver-dependent vision.

[Psychosocial strategies to strengthen the coping with Parkinson's disease: Perspectives from patients, family carers and healthcare professionals]. / Estrategias psicosociales para fortalecer el afrontamiento de la enfermedad de Parkinson: perspectiva de pacientes, familiares y profesionales sociosanitarios.

OBJECTIVE: To explore the main psychosocial aspects which have influence on the coping with the disease in patients with Parkinson's disease (PD) and their family carers. DESIGN: An exploratory qualitative study which constitutes the second phase of a mixed-methods project. SETTING: Multicenter study carried out in Navarre in 2014 in collaboration with Primary Care of Navarre Service of Health-Osasunbidea, Clínica Universidad de Navarra and Navarre Association of Parkinson's patients. PARTICIPANTS: A total of 21 participants: 9 people with PD, 7 family carers and 5 healthcare professionals. METHOD: Participants were selected through purposive sampling. Focus groups were conducted until a suitable saturation data was achieved. Transcriptions were analysed by 2 researchers through a content analysis. RESULTS: Three aspects that affected how patients and family carers coped with PD were identified: features of the clinical practice; family environment, and disease's acceptance. Taking account of these findings, some strategies which could foster these aspects from primary healthcare are suggested in order to improve the adjustment to the disease in patients and family carers. CONCLUSIONS: The healthcare in people with PD should have an integral approach that tackle the symptoms control in patients and also deal with psychosocial aspects that influence on the coping with the disease, in patients and family carers.

The impact of the patient post-intensive care syndrome components upon caregiver burden.

OBJECTIVE: To evaluate patient post-intensive care syndrome (PICS-P) and caregiver burden 3 months after discharge from the Intensive Care Unit (ICU) and determine the impact of different components of PICS-P upon caregiver burden. DESIGN: A prospective observational study was conducted over 26 months (January 2013-February 2015). SETTING: Medical-surgical ICU and follow-up consultation in Portugal. PATIENTS OR PARTICIPANTS: Patients discharged after a minimum of 2 days in the ICU. Caregiver inclusion criteria: not paid, written and spoken Portuguese, and agreement to participate in the study. MAIN VARIABLES OF INTEREST: In ICU: Patient gender, age, severity of illness (SAPS II) and length of ICU stay. At 3 months caregiver burden, physical (reduced mobility, weakness acquired in the ICU) and psychological components of PICS (anxiety, depression, post-traumatic stress disorder). RESULTS: A total of 168 caregivers completed the survey (response rate of 69%). A low degree of overburden was reported by 34.5% of caregivers, while 15.5% showed moderate to high levels of overburden. Patient anxiety and depression 3 months after ICU discharge significantly influenced the presence of caregiver burden (p=0.030 vs p=0.008). When physical components of PICS-P were evaluated, no influence on caregiver burden was observed. Patient demographics, severity of illness and length of stay also failed to influence caregiver burden. CONCLUSIONS: The presence of psychological components of PICS-P 3 months after ICU seems to have a negative impact upon caregiver burden. On the other hand, physical problems showed no important impact upon caregiver overburden.

"EFFECTIVE VOLUNTEERISM:" HELPING CHILD CAREGIVERS IN DEVELOPING COUNTRIES.

This article proposes a method of volunteering mental health consultation to child caregivers in developing countries in the context of episodic visits and a long-term relationship. It is derived from the author's experience doing this work for approximately 12 years. The two foundational features of the method-the role of a consultant and a long-term relationship-are described. The method is then elaborated in two settings: consultation to caregivers in an orphanage in Central America and at a hospital in India. While these examples are distinct in multiple domains, they have in common the core features of the consultative model and a long-term relationship. Finally, the article briefly addresses challenges that the consultant experiences when working with neglected and traumatized children and the usefulness of reflective practice. It is hoped that an articulation of this method may make it possible for many who might wish to volunteer to do so, in a way that neither interferes significantly with their work and family life at home nor creates the problems of "helicopter volunteering."