Abstract
Background
Caregivers of patients with major depressive disorder (MDD) frequently experience significant mental health and social burdens, yet evidence among Asian caregivers remains limited. This study aimed to identify factors associated with caregiver burden in the Taiwanese population.
Methods
A cross-sectional survey of 150 caregiver–patient pairs was conducted in a psychiatric outpatient clinic in Taiwan. Caregiver burden, common mental symptoms, and depressive symptoms were assessed using validated instruments. Correlation and hierarchical regression analyses were performed to determine factors related to total and subdomain caregiver burden.
Results
Caregivers reported a mild to moderate level of burden, with the highest index score in caregiver strain, and lowest in stigma. Both common mental symptoms and depressive symptoms were significantly correlated with total burden. Regression analyses showed that caregiver educational attainment and depressive symptoms were the strongest factors related to total burden, together explaining 43.7% of the variance. Depression severity also emerged as the key factor across several burden subdomains.
Conclusion
Caregivers of MDD patients experience meaningful levels of burden, largely influenced by their mental health status, particularly depressive symptoms. These findings emphasize the need for targeted mental health assessment and supportive interventions to reduce caregiver burden and promote caregiver well-being.
Keywords: caregiver burden, MDD, common mental symptoms, educational attainment
Introduction
Caregivers of people with chronic disease, particularly primary (informal) caregivers such as family members, experience significant burdens in various areas of life. These include emotional and psychological impacts such as stress, anxiety and depression; physical impacts such as health decline and fatigue; financial impacts such as lost income and out-of-pocket costs; and social impacts such as stigma, isolation and relationship strain.1 A substantial proportion of mental illness have been shown to impose a considerable burden on caregivers. However, schizophrenia attracts more attention than other conditions due to the deterioration of patients’ individual and social performance, and the symptoms that affect caregivers’ quality of life.2,3 Conversely, major depressive disorder (MDD) is one of the most prevalent and disabling mental health disorders. The extant literature suggests that the consequences of depression and schizophrenia for caregivers are highly similar.4 A study conducted in 2021 examined the humanistic and economic burden of caregiving for adults with depression, in comparison to caregiving for those with a chronic illness and the general non-caregiving population in five major Western European countries. The findings indicate that caregivers of depression appear to experience a heightened burden, characterized by diminished health-related quality of life, elevated productivity impairment, and augmented healthcare resource utilization, in comparison to caregivers of other chronic illnesses and the general non-caregiving population.5 Nevertheless, the current evidence is insufficient to address its impact on caregivers of depressed patients, especially in the Asian population.
A recent systemic review article in 2022 shows that informal caregivers of patients with mental disorders face high levels of distress. The meta-analysis of caregivers of all psychiatric patients estimated that about 31.7% of caregivers report significant burden.6 Of the included studies, a mere two focused on the caregiver burden of elderly MDD patients (published in 2002 and 2010).7,8 Nevertheless, both studies analyzed a limited number of samples and demonstrated primarily the association between family burden and the severity of depression or disability exhibited by patients. A study of caregivers of people with depression in Nigeria found that close to half of the caregivers experienced moderate to severe burden, as measured by the Zarit Burden Interview and General Health Questionnaire.9 Zhang et al conducted a study in which 240 family caregivers of adolescents with depression were recruited from a tertiary hospital in China.10 The study reported a prevalence of 78.8% for caregiving burden. It was also reported that negative emotion was associated with a poorer mental quality of life among caregivers. While some literature exists regarding caregivers of individuals with mental illnesses, research specifically focusing on the primary caregivers of patients with major depressive disorder is relatively limited, especially in the Asian population. The present study aims to explore the factors associated with the caregiver burden experienced by primary caregivers of Taiwanese patients with MDD. It is anticipated that the findings of this study will serve as a valuable reference point for the development of future interventions targeting this vulnerable group, with the objective of reducing the physical, mental, and social burden on caregivers.
The objectives of this study are as follows. First, to understand the socio-demographic and clinical characteristics of primary caregivers of MDD patients, including common mental symptoms (anxiety, insomnia, somatic complaints), depression, and caregiver burden. Second, to understand the associated factors of caregiver burden from associated factors such as socio-demographic of both patients and caregivers, and the mental health status of caregivers. The study hypothesized that specific sociodemographic factors of the caregivers, such as their relationship to the patient and their own mental health status, would be significantly associated with the severity of the caregiving burden.
Methods
Study Design and Participants
The cross-sectional design was selected for this study because it efficiently facilitates the simultaneous evaluation of multiple patient and caregiver variables and their associations with caregiver burden at a specific point in time. This approach is firmly supported by research in the field of caregiver studies. For instance, the seminal work by Zarit et al (1980) employed a cross-sectional survey method to identify the fundamental correlates of caregiver burden.11 Moreover, the present design maintains its relevance in contemporary psychiatric research, as evidenced by recent studies (eg., Lee et al, 2023) that employed cross-sectional methods to evaluate burden and associated factors among caregivers of patients with depressive disorders.12 Collectively, these studies demonstrate that a cross-sectional methodology is both historically validated and currently applicable for identifying high-risk caregiving groups.
We recruited primary caregivers of patients diagnosed with MDD who attended the psychiatric outpatient clinic of the E-Da Hospital in Kaohsiung, Taiwan, between September 2019 and January 2020. Specifically, patients were required to be in a state of clinical remission, operationally defined as having a Clinical Global Impressions-Severity (CGI-S) score of < 2 (borderline mentally ill), with regularly scheduled follow-ups in our psychiatric outpatient clinic for a minimum of one year, with no psychiatric emergency room visits or acute psychiatric ward admissions during the past year, as evaluated by psychiatrists. Eligible participants were (1) aged ≥20 years; and (2) the primary caregiver who spent the most time providing care to the patient with MDD, confirmed by a psychiatrist according to the DSM-5 diagnostic criteria, and who did not receive any financial compensation for caregiving. Caregiving tasks typically included preparing meals, managing finances, providing emotional or financial support, and accompanying the patient to medical visits. Exclusion criteria included (1) refusal to participate or incomplete questionnaire data; and (2) communication or cognitive impairments that hindered comprehension or response accuracy. The survey collected sociodemographic information on both patients and caregivers, and assessed caregiver’s common mental symptoms, depressive symptoms, and caregiver burden. To minimize potential bias, all interviews were conducted by a trained research assistant following standardized procedures, and all questionnaires were checked for completeness before data entry. The required sample size was estimated using G*Power software for multiple linear regression, fixed model, R2 deviation from zero.13 Assuming a significance level (α) of 0.05, a statistical power (1–β) of 0.80, a medium effect size (f2) of 0.15, and 16 independent variables in the regression model, the minimum required sample size was estimated to be 143 participants. To ensure adequate power and account for possible non-response or incomplete data, a total of 160 primary caregivers of patients with MDD were initially approached. Among them, 5 caregivers declined to participate, and 2 were excluded for not meeting the inclusion criteria. Consequently, 153 caregivers consented and received the survey questionnaires. After excluding 3 responses due to extensively incomplete data, a final sample of 150 valid responses was included in the analysis, yielding an effective response rate of 94.9%. The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of E-Da Hospital (IRB number: EMRP17108N). All participants provided written informed consent. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for cross-sectional studies to ensure completeness and transparency of reporting.14
Variables and Measures
Measurement of Caregiver Burden
Caregiver burden was assessed using the Caregiver Burden Scale developed by Song (2002), which evaluates both subjective and objective aspects of burden among family caregivers of patients with mental illness. The instrument contains 16 items scored on a 5-point Likert scale (0 = never to 4 = always), with higher scores indicating greater burden. It comprises five subdomains: family/career interference (items 2, 3, 6, 8, 9, 11, 15, from 0 to 28 points), stigma (items 13 and 14, from 0 to 8 points), guilt (items 1 and 4, from 0 to 8 points), caregiver strain (items 5, 7, and 16, from 0 to 12 points), and care recipient dependency (items 10 and 12, from 0 to 8 points). With the exception of family/career Interference, which falls under objective burden, the remaining subdomains fall under subjective burden. The scale demonstrated excellent internal consistency in the original validation study (Cronbach’s α = 0.88).15 This tool continues to be utilized in subsequent caregiver studies in Taiwan.16,17 In the present study, the internal consistency reliability was also high, with Cronbach’s α = 0.88 for the total scale and α values ranging from 0.74 to 0.85 across the five subdomains, indicating good reliability.
Measurement of Common Mental Symptoms
Common mental symptoms were assessed using the 12-item Chinese Health Questionnaire (CHQ) developed by Cheng and Williams.18 The CHQ was designed to screen for minor psychiatric morbidity (especially anxiety symptoms) and psychosomatic distress in Chinese populations. Respondents rated 12 items on a 12-question, 2-reverse question, 0–1-point questionnaire. The items covered both negatively and positively worded statements concerning psychosocial well-being, such as headaches, palpitation, chest tightness, limbs shivering, poor sleep, nervousness, worries, self-confidence, and hopelessness. Following the original scoring procedure, higher total scores indicate severe common mental symptoms. The total score ranges from 0 to 12. The CHQ has demonstrated good internal consistency and construct validity in both community and clinical settings, with Cronbach’s α = 0.84.19 The CHQ continues to be employed as a reliable assessment instrument in recent clinical studies involving Taiwanese populations.20 In the present study, the internal consistency of the CHQ was satisfactory (Cronbach’s α = 0.78), indicating acceptable reliability.
Measurement of Depression Symptoms
Caregivers’ depression symptoms were assessed using the Taiwan Depression Questionnaire (TDQ), an 18-item self-report scale developed for Mandarin-speaking populations and validated in both psychiatric and community samples.21 Each item is rated from 0 (not at all) to 3 (nearly every day), yielding a total score ranging from 0 to 54. According to established cut-offs, scores of 0–8 indicate normal, 9–14 indicate mild depression, 15–18 indicate moderate depression, and scores ≥19 indicate severe depression (meeting the MDD cutoff point). The TDQ covers affective, cognitive, and somatic dimensions of depression and has demonstrated good internal consistency (Cronbach’s α = 0.90) and satisfactory criterion validity against DSM-based clinical diagnoses. In recent clinical studies involving Taiwanese populations, TDQ has been employed as a reliable assessment instrument.22 In the present study, the internal consistency of the TDQ was excellent (Cronbach’s α = 0.94), indicating very high reliability.
Sociodemographic and Clinical Variables
Patient variables included age, sex, marital status, educational attainment, occupation, and disability status. Regarding the disability categories, these grades are officially determined based on the national guidelines for issuing the Disability Certificate in Taiwan. The grading system evaluates the degree to which a psychiatric disorder causes chronic impairment in a patient’s self-care abilities, occupational functioning, and psychosocial functioning, despite adequate psychiatric treatment. Caregiver variables comprised age, sex, educational attainment, marital and occupation status, relationship to the patient, average monthly income, and caregiving duration.
Statistical Analysis
Descriptive statistics were used to summarize the demographic characteristics and major variables. Group differences in total caregiver burden according to caregiver sociodemographic characteristics were examined using independent-samples t-tests. To facilitate group comparisons and avoid sparse subgroup sizes, several categorical variables with multiple levels were collapsed into binary groups for analysis. Mean differences, corresponding 95% confidence intervals (CIs), and Cohen’s d effect sizes were additionally calculated to improve the interpretability of group comparisons. Pearson’s correlation coefficients were used to evaluate the associations among continuous variables, including age, years of caregiving, CHQ scores, TDQ scores, and caregiver burden scores. Multiple linear regression analyses using a hierarchical entry approach were conducted to examine factors associated with caregiver burden. Prior to the multiple linear regression analyses, categorical variables were transformed into binary dummy variables for model estimation and interpretation. For all binary variables, the first listed category served as the reference group. Continuous variables included patient age, caregiver age, caregiving duration, CHQ scores, and TDQ scores. In the first stage (Model 1), variables related to patient and caregiver characteristics were entered into the model to control for potential clinical and demographic influences. Subsequently, caregivers’ common mental symptoms measured by the CHQ were added in the second stage (Model 2) to examine the incremental contribution to caregiver burden. In the final stage (Model 3), caregivers’ depression symptoms assessed by the TDQ were introduced to evaluate the additional explanatory power of depression beyond demographic characteristics and caregivers’ common mental symptoms. Changes in model explanatory power were evaluated by the coefficient of determination (R2), adjusted R2, ΔR2, F change, and p for F change. A significant F change was interpreted as a meaningful improvement in model explanatory power after adding a new block of independent variables. Multicollinearity was examined using variance inflation factor (VIF < 10). In addition, a sensitivity analysis excluding caregivers with severe depressive symptoms (TDQ ≥19) was performed to evaluate the robustness of the regression findings. Given the exploratory nature of the analyses, no formal adjustment for multiple comparisons was applied. All tests were two-tailed, and p <0.05 was considered statistically significant. All analyses were performed using SPSS version 20.0 for Windows (IBM, USA).
Results
MDD Patient and Caregiver Characteristics
A total of 150 patients with MDD and their primary caregivers were included in the analysis. The mean age was 55.88 ± 19.50 years for patients and 55.06 ± 11.90 years for caregivers. More than half of both patients (54.7%) and caregivers (53.3%) were female. Among patients, 67.4% were married, and 30.7% had completed senior high/vocational school, while 22.6% had only elementary education. For caregivers, 80.7% were married and 44.0% had completed senior high/vocational education; 60.0% were employed. Nearly half of caregivers (46.0%) had a monthly income below NTD$ 20,000, and 44.7% were spouses of the patients. The average duration of caregiving was 5.45 ± 5.2 years. Regarding mental health status, the mean CHQ score was 4.35 ± 2.76 and the mean TDQ score was 12.56 ± 11.97; 24.0% of caregivers had severe depression, while 49.3% showed no depression symptoms. The mean total caregiver burden score was 20.4 ± 11.3, indicating a mild to moderate level of burden. Among the five subdomains, the highest scores were observed in family/career interference (7.40 ± 6.08), followed by caregiver strain (6.17 ± 3.12) and care recipient dependency (3.79 ± 2.34), while stigma (0.47 ± 1.21) was the lowest (Table 1). Furthermore, the “caregiver strain” subdomain had the highest average score per item (2.06 ± 1.04), with an “index score” of 51.4 for this subdomain. The “stigma” subdomain had the lowest average score per item (0.23 ± 0.60), with an “index score” of 5.88.
Table 1.
Sociodemographic and Health-Related Characteristics of Patients with Major Depressive Disorder and Their Primary Caregivers
| Characteristics | MDD Patients | Primary Caregivers |
|---|---|---|
| Participants (n) | 150 | 150 |
| Age (years) | 55.88 ± 19.50 | 55.06 ± 11.90 |
| Age | ||
| ≤40 years | 30 (20.0) | 19 (12.7) |
| 41–50 years | 29 (19.3) | 45 (30.0) |
| 51–60 years | 23 (15.3) | 50 (33.3) |
| 61–70 years | 30 (20.0) | 23 (15.3) |
| >70 years | 38 (25.4) | 13 (8.7) |
| Sex | ||
| Male | 68 (45.3) | 70 (46.7) |
| Female | 82 (54.7) | 80 (53.3) |
| Marital status | ||
| Married | 101 (67.4) | 121 (80.7) |
| Cohabiting | 6 (4.0) | 6 (4.0) |
| Unmarried/divorced | 32 (21.3) | 20 (13.3) |
| Widowed | 11 (7.3) | 3 (2.0) |
| Educational attainment | ||
| No formal education | 18 (12.0) | 2 (1.3) |
| Elementary school | 34 (22.6) | 17 (11.4) |
| Junior high school | 24 (16.0) | 15 (10.0) |
| Senior high/vocational school | 46 (30.7) | 66 (44.0) |
| College | 25 (16.7) | 45 (30.0) |
| Master’s degree | 3 (2.0) | 5 (3.3) |
| Occupation | ||
| None | 53 (35.3) | 49 (32.7) |
| Homemaker | 39 (26.0) | 11 (7.3) |
| Agriculture | 7 (4.7) | 6 (4.0) |
| Industry | 32 (21.3) | 64 (42.7) |
| Business | 6 (4.0) | 20 (13.3) |
| Others | 13 (8.7) | 0 (0.00) |
| Grade of disability | ||
| None | 108 (72.0) | – |
| Mild | 22 (14.7) | – |
| Moderate | 15 (10.0) | – |
| Severe | 5 (3.3) | – |
| Average monthly income (NTD) | ||
| <20,000 | – | 69 (46.0) |
| 20,000–40,000 | – | 51 (34.0) |
| 40,000–60,000 | – | 22 (14.7) |
| >60,000 | – | 8 (5.3) |
| Relationship to the patient | ||
| Spouse | – | 67 (44.7) |
| Son/daughter | – | 41 (27.3) |
| Daughter-in-law/son-in-law | – | 8 (5.3) |
| Others | – | 34 (22.7) |
| Caregiving (years) | – | 5.45 ± 5.2 |
| Caregiving | – | |
| ≤5 years | – | 78 (52.0) |
| 6–10 years | – | 40 (26.7) |
| 11–20 years | – | 15 (10.0) |
| ≥20 years | – | 17 (11.3) |
| Common mental symptoms (CHQ) | – | 4.35 ± 2.76 |
| Depression symptoms (TDQ) | – | 12.56 ± 11.97 |
| Depression severity | ||
| Normal | – | 74 (49.3) |
| Mild depression | – | 28 (18.7) |
| Moderate depression | – | 12 (8.0) |
| Severe depression | – | 36 (24.0) |
| Caregiver burden scale | 20.4 ± 11.3 | |
| Family/career interference | – | 7.40 ± 6.08 |
| Stigma | – | 0.47 ± 1.21 |
| Guilt | – | 2.56 ± 2.12 |
| Caregivers’ strain | – | 6.17 ± 3.12 |
| Care recipient dependency | – | 3.79 ± 2.34 |
| Caregiver burden level | ||
| None | – | 19 (12.7) |
| Mild to moderate burden | – | 59 (39.3) |
| Moderate burden | – | 51 (34.0) |
| Moderate to severe burden | – | 16 (10.7) |
| Severe burden | – | 5 (3.3) |
Note: Burden levels were categorized as follows: None <8 points; Mild to moderate burden = 8–20 points; Moderate burden = 21–32 points; Moderate to severe burden = 33–44 points; Severe burden ≥45 points.
Abbreviations: CHQ, Chinese Health Questionnaire; TDQ, Taiwanese Depression Questionnaire.
Comparison of Caregiver Burden by Sociodemographic Characteristics
The comparison of caregiver characteristics and total burden revealed that educational level was significantly associated with caregiver burden (p = 0.006). Caregivers with senior high school education or above (21.76 ± 10.96) reported higher burden than those with junior high school or below (15.79 ± 10.61), with a moderate effect size (Cohen’s d= 0.55). No statistically significant differences were observed for sex, occupation, marital status, monthly income, or relationship to the patient, all of which showed small effect sizes (Table 2). These findings suggest that caregivers’ education was a key sociodemographic factor related to the perceived caregiver burden in this sample.
Table 2.
Comparison of Sociodemographic Characteristics and Total Caregiver Burden Among Primary Caregivers
| Characteristics | n (%) | Mean ± SD | t | Mean Difference (95% CI) | p | Cohen’s d |
|---|---|---|---|---|---|---|
| Sex | −0.81 | (−5.09, 2.12) | 0.417 | 0.13 | ||
| Male | 70 (46.7) | 19.61 ± 10.13 | ||||
| Female | 80 (53.3) | 21.10 ± 11.97 | ||||
| Educational attainment | −2.81 | (−10.16, 1.77) | 0.006 | 0.55 | ||
| Junior high school or below | 34 (22.7) | 15.79 ± 10.61 | ||||
| Senior high school or above | 116 (77.3) | 21.76 ± 10.96 | ||||
| Occupation | −0.05 | (−3.95, 3.76) | 0.961 | 0.01 | ||
| Unemployed | 60 (40.0) | 20.35 ± 12.59 | ||||
| Employed | 90 (60.0) | 20.44 ± 10.12 | ||||
| Marital status | −1.65 | (−8.29, 0.75) | 0.102 | 0.34 | ||
| Married | 121 (80.7) | 19.68 ± 11.40 | ||||
| Cohabiting/unmarried/divorced | 29 (19.3) | 23.45 ± 9.55 | ||||
| Average monthly income (NTD) | 1.04 | (−1.77, 5.69) | 0.300 | 0.18 | ||
| <20,000 | 69 (46.0) | 21.46 ± 13.36 | ||||
| ≥20,000 | 81 (54.0) | 19.51 ± 8.79 | ||||
| Relationship to patient | −0.80 | (−5.62, 2.39) | 0.426 | 0.15 | ||
| Spouse/son/daughter | 108 (72.0) | 19.95 ± 11.10 | ||||
| In-law/others | 42 (28.0) | 21.57 ± 11.26 |
Note: Mean differences were calculated as the difference between the first and second listed groups. Corresponding 95% confidence intervals were calculated using independent-samples t-tests. Cohen’s d values are presented as absolute effect sizes.
Correlations Between Common Mental Symptoms, Depression Symptoms, and Caregiver Burden
Correlation analysis showed that both common mental symptoms (CHQ) and depression symptoms (TDQ) were positively and strongly correlated with the total caregiver burden (r = 0.489, p <0.01; r = 0.593, p <0.01, respectively). Among the five subdomains, caregivers’ depression symptoms were significantly associated with family/career interference (r = 0.559, p <0.01), guilt (r = 0.398, p <0.01), caregiver strain (r = 0.475, p <0.01), and care recipient dependency (r = 0.326, p <0.01), but not with stigma (r = 0.082, p >0.05). In addition, caregivers’ common mental symptoms were positively correlated with all subdomains, most strongly with family/career interference (r = 0.436, p <0.01). Age was negatively correlated with guilt (r = –0.253, p <0.01), indicating that younger caregivers experienced greater guilt. No statistically significant correlations among years of caregiving and caregiver burden were found (Table 3).
Table 3.
Correlation Analysis of Continuous Caregiver-Related Variables with Total Caregiver Burden and Subdomains
| Characteristics | Age | Years of Caregiving | CHQ | TDQ |
|---|---|---|---|---|
| Total caregiver burden | −0.151 | 0.151 | 0.489** | 0.593** |
| Family/career interference | −0.048 | 0.139 | 0.436** | 0.559** |
| Stigma | −0.044 | −0.044 | 0.318** | 0.082 |
| Guilt | −0.253** | 0.133 | 0.254** | 0.398** |
| Caregiver strain | −0.149 | 0.112 | 0.431** | 0.475** |
| Care recipient dependency | −0.141 | 0.108 | 0.220** | 0.326** |
Note: **p <0.01.
Abbreviations: CHQ, Chinese Health Questionnaire; TDQ, Taiwanese Depression Questionnaire.
Factors Associated to Total and Subdomain Caregiver Burden
In Model 1, patient and caregiver characteristics alone explained 19.0% of the variance in total caregiver burden (R2 = 0.190). None of the individual patient variables reached statistical significance, but this block provided a baseline level of explanatory power. In Model 2, caregiver CHQ scores were added, and the model’s explanatory power increased to R2 = 0.356 (adjusted R2 = 0.284). The change in variance explained was ΔR2 = 0.166, with a significant F change of 34.486 (p <0.001), indicating that adding caregiver common mental symptoms significantly improved the model. In this step, caregiver educational attainment (β = 0.299, p <0.01) and common mental symptoms (CHQ; β = 0.446, p <0.01) were significantly associated with higher caregiver burden. In Model 3, caregiver depression symptoms (TDQ) were further included. The final model explained 43.7% of the variance (R2 = 0.437; adjusted R2 = 0.369). The incremental variance explained by adding TDQ was ΔR2 = 0.081, and the F change was 19.188 (p <0.001), demonstrating that depression symptoms provided a substantial additional contribution beyond previous blocks. In the final model, caregiver educational attainment (β = 0.209, p <0.05) and depression symptoms (TDQ; β = 0.449, p <0.001) remained significantly associated with total caregiver burden, whereas CHQ was no longer significant (β = 0.120, p >0.05). This pattern suggests that depression symptoms accounted for a large proportion of the mental health indicators previously explained by common mental symptoms, indicating conceptual overlap rather than problematic statistical multicollinearity (Table 4).
Table 4.
Analyses of Multiple Linear Regression for Total Caregiver Burden Among Primary Caregivers
| Variables | Model 1 | Model 2 | Model 3 | Model 3 (TDQ <19) | ||||
|---|---|---|---|---|---|---|---|---|
| β | t | β | t | β | t | β | t | |
| MDD participants | ||||||||
| Age (years) | −0.125 | −0.952 | −0.148 | −1.257 | −0.128 | −1.162 | −0.159 | −1.127 |
| Sex | 0.016 | 0.154 | 0.017 | 0.182 | 0.013 | 0.143 | −0.070 | −0.614 |
| Educational attainment | 0.069 | 0.606 | 0.001 | 0.014 | 0.010 | 0.101 | −0.151 | −1.269 |
| Marital status | −0.161 | −1.564 | −0.113 | −1.220 | −0.157 | −1.795 | −0.101 | −0.894 |
| Occupation | −0.145 | −1.591 | −0.068 | −0.831 | −0.057 | −0.737 | 0.005 | 0.051 |
| Grade of disability | 0.029 | 0.355 | 0.067 | 0.894 | 0.050 | 0.710 | 0.086 | 1.007 |
| Primary caregivers | ||||||||
| Age (years) | −0.069 | −0.609 | 0.007 | 0.067 | 0.056 | 0.578 | 0.023 | 0.185 |
| Sex | 0.069 | 0.669 | −0.005 | −0.056 | 0.006 | 0.071 | −0.023 | −0.223 |
| Educational attainment | 0.256 | 2.542* | 0.299 | 3.309** | 0.209 | 2.389* | 0.347 | 3.035** |
| Marital status | 0.143 | 1.569 | 0.092 | 1.127 | 0.087 | 1.127 | 0.024 | 0.247 |
| Occupation | 0.157 | 1.398 | 0.081 | 0.800 | 0.085 | 0.895 | 0.094 | 0.780 |
| Average monthly income (NTD) | −0.346 | −2.952** | −0.198 | −1.838 | −0.145 | −1.422 | −0.123 | −0.973 |
| Relationship to the patient | 0.091 | 0.947 | 0.038 | 0.440 | 0.124 | 1.482 | 0.122 | 1.207 |
| Caregiving (years) | 0.213 | 2.625** | 0.111 | 1.496 | 0.127 | 1.813 | 0.251 | 2.922** |
| Common mental symptoms (CHQ) | 0.446 | 5.873*** | 0.120 | 1.167 | 0.143 | 1.312 | ||
| Depression symptoms (TDQ) | 0.449 | 4.380*** | 0.394 | 3.615*** | ||||
| R2 | 0.190 | 0.356 | 0.437 | 0.383 | ||||
| Adjusted R2 | 0.106 | 0.284 | 0.369 | 0.281 | ||||
| F change | 3.349 | 34.486 | 19.188 | – | ||||
| p for F change | 0.002 | <0.001 | <0.001 | – | ||||
Note: **p <0.01; ***p <0.001. Continuous variables included patient age, caregiver age, caregiving duration, CHQ scores, and TDQ scores. All categorical variables were entered as binary dummy variables, with the first listed category serving as the reference group.
Abbreviations: CHQ, Chinese Health Questionnaire; TDQ, Taiwanese Depression Questionnaire.
Sensitivity analyses excluding caregivers with severe depressive symptoms (TDQ ≥19) demonstrated generally similar findings (Table 4). In particular, caregiver educational attainment and TDQ scores remained positively associated with caregiver burden, while caregiving duration became significantly associated with caregiver burden after excluding caregivers with more severe depressive symptoms.
For the subdomain analyses, the family/career interference dimension was significantly influenced by patients’ marital status, caregivers’ monthly income, and depression symptoms, whereas stigma was mainly associated with caregivers’ educational attainment, relationship to the patient, common mental symptoms, and depression symptoms. The guilt, caregiver strain, and care recipient dependency dimensions were all predominantly explained by depression symptoms, highlighting the central role of mental health issues in shaping different aspects of caregiver burden. Overall, caregivers with higher education and more severe depression symptoms experienced greater burden across multiple aspects (Table 4).
Discussion
The current study assessed the caregiver burden of Taiwanese patients with MDD. The study results showed that the primary caregiver’s total caregiving burden is found within the mild to moderate range. Among the subdomains, the highest average score was recorded for “family/career interference,” followed by “caregiver strain”, and “care recipient dependency”, while “stigma” exhibited the lowest average score. This study also illustrated that the educational attainment of the primary caregiver, in addition to the severity of their depression, are significantly associated with the total caregiving burden. These factors were identified as key explanatory variables, accounting for 43.7% of the total variance observed in the regression model.
The following are the details of the socio-demographic and clinical characteristics of primary caregivers (which were associated with caregiver burden in the present study): the average age of primary caregivers was 55.06 ± 11.90. The data revealed that the female population constituted the majority of the sample, with 80 individuals identified as female, representing 53.3% of the total sample. Most of the participants had attained a high school or vocational school qualification, with 66 individuals (44.0%) falling into this category. This was followed by those with a college or university degree, with 45 individuals (30.0%) falling into this category. Furthermore, 3 individuals (2.0%) held a master’s degree. The primary caregivers in this study had a mean total TDQ score of 12.56 ± 11.97. Thirty-six caregivers (24%) met the MDD cutoff point, indicating that approximately one-quarter of primary caregivers may require referral to mental health resources for assistance. The demographics of the current study are consistent with those of previous studies of physical and mental illnesses, with the majority of caregivers being women in their mid-40s, married, and with a higher prevalence of anxiety and depression issues.23,24 A Taiwanese study undertaken in 2021 reported that depressive disorders constituted the most prevalent psychiatric diagnosis (25.8%) among a sample of 120 caregivers of patients with depressive disorders.12 However, the local study identified MDD as 12.5% among the depressive disorders categories, compared to 24% in our study. One potential explanation for this discrepancy is that our sample was from a more specific population, caregivers of MDD patients, who might have more psychosocial stress than other minor depressive patients. In a recent Taiwanese study (n = 459 family caregivers of patients with mental illness, including 159 MDD patients) examining the influence of caregiver mental health and care burden on quality of life, the mean TDQ score was found to be 10.1 (± 9.5), which was far below the clinical cut-off value of 20.25 This discrepancy in reported caregiver depressive symptoms may be attributed to differences in sample characteristics. Specifically, the results of the aforementioned study indicated that the strictly defined “primary caregiver” accounted for only 85.6% of all participants, and the average educational attainment among their caregivers was lower (9.9 ± 4.7 years) compared to our study. A further online survey conducted in China, which recruited a total of 1,224 informal caregivers of mental illnesses (including 105 MDD patients), demonstrated that 53.5% of the participants exhibited moderate to severe depression, while 43.1% demonstrated moderate to severe anxiety.26 However, the distribution of the questionnaires in the aforementioned study was conducted through online platforms, a method which may potentially exclude potential participants who lack access to the Internet or are not familiar with online survey tools. This may be particularly relevant for older informal caregivers and those residing in rural areas.
The present study showed an interesting finding that the educational attainment of the primary caregiver was associated with total caregiver burden, as well as the subdomains of “care recipient dependency” and “stigma”. The importance of caregiver education in the caregiving experience cannot be overstated. In accordance with the Stress Process Model of caregiving, informal caregivers from lower socio-economic position (SEP) are hypothesized to experience elevated levels of caregiver burden, attributable to their constrained access to stress-buffering resources.27 On a global scale, studies consistently demonstrate that caregivers with higher SEP tend to experience reduced workloads and enhanced coping mechanisms. Conversely, lower SEP is often associated with a greater burden.28 A study of caregivers of spinal cord injury in Switzerland demonstrated that education exhibited a negative correlation with objective caregiver burden, while subjective social position demonstrated a negative correlation with subjective caregiver burden.29 In contrast, a study of caregivers in Germany suggested that individuals with a higher educational attainment were more likely to experience mental burdens associated with caregiving, in comparison to caregivers with a lower educational background.30 Furthermore, the study also found that caregivers with a higher educational attainment were less likely to experience physical burdens associated with caregiving. The authors hypothesized that this increased mental burden results from feared losses of autonomy, which increase with higher investment in education. A study of caregivers of older cancer patients, as reported in the 2025 issue of the Journal of the American Medical Association’s Health Forum, revealed a complex pattern. While a higher income led to a reduction in financial pressure, a higher level of education was found to be associated with an increase in psychological burden.31 The authors posit that caregivers with superior health literacy, who have received greater education, tend to be more involved in the decision-making process and the day-to-day management of their patients’ care. This increased participation, however, can concomitantly result in elevated levels of anxiety and self-imposed demands, which, in turn, can adversely impact the quality of care delivered. However, the extant literature offers scant support for the hypothesis that social inequalities are associated with caregiver burden in the MDD population. Further studies should be conducted to clarify the association between SEP (education) and caregiver burden.
The care of family members suffering from serious mental illness is frequently accompanied by stigma, and a higher level of stigma is associated with a higher degree of mental health morbidity in the caregiver.32,33 Research has also documented the tendency of family caregivers to internalize discriminatory attitudes towards themselves, leading to the development of self-stigma.34 In the present study, we found that educational attainment, other relationships with the patient (excluding spouse or children), common mental symptoms, and depressive symptoms are all significantly associated with stigma. Comparing our findings with recent international literature provides a broader context for the caregiving burden. A recent cross-sectional study by Leta et al (2025) in Ethiopia also found a high prevalence of caregiver burden (52.8%) among outpatient psychiatric caregivers, including those caring for depressive disorder patients (36.5%).35 While Leta et al primarily highlighted socio-economic determinants, such as social support, receiving help with care, and perceived stigma, our study notably incorporated caregivers’ mental health characteristics. Beyond socio-demographic factors, our findings emphasize that the caregivers’ own mental distress significantly correlates the overall burden (which included stigma as a subdomain). A recent qualitative study conducted in Pakistan explored the phenomenon of “daughter-in-law providing elderly care”, and the findings revealed that participants experienced a range of physical and emotional effects within the context of a collectivist and patrilocal society in South Asia.36 In addition, extant research has demonstrated the impact of differing care-recipient relationship types on the mental health burden experienced by caregivers for the elderly and even those diagnosed with schizophrenia.37,38 Nevertheless, the evidence correlating relationship type with stigma remains sparse in MDD patients. Consequently, clinicians treating patients with severe mental disorders must prioritize addressing stigma and mental health status among caregivers, whilst devising intervention strategies to combat stigma.
It is evident from the findings of this study that there are several significant clinical implications that can be drawn. These implications can be used to advance the development of a comprehensive social care and support system for informal caregivers of Taiwanese MDD patients. Firstly, there is a necessity to strengthen advocacy efforts in order to raise public awareness of the needs of informal caregivers of MDD patients. Secondly, a range of supportive strategies and services for informal caregivers of MDD patients should be established and evaluated in the long-term care context. Such strategies may include psychological counselling, care skills training, respite care, caregiver support groups, and financial benefits. It is important to note that all of these strategies have been overlooked in long-term psychiatric patient care to date. Finally, data collection in the study was conducted from September 2019 to January 2020, serving as a pre-pandemic baseline. The Coronavirus Disease 2019 (COVID-19) pandemic has had a substantial and long-lasting effect on this demographic, with the potential to modify the caregiving environment and intensify the burden on caregivers. Consequently, the findings of this study may not fully reflect the current realities faced by caregivers in the post-pandemic era. Comparing our pre-pandemic data with recent research on China populations during the late pandemic stage (eg., Sun et al, 2024) reveals a consistent emphasis on caregiver mental health.39 Although Sun et al focused on the network structure of depression and anxiety symptoms rather than directly measuring “caregiver burden”, their findings highlight that fatigue, trouble relaxing and restlessness were the most central symptoms in the network of depression and anxiety. This strongly complements our results, which identify caregivers’ own common mental symptoms and correlate with their overall burden, underscoring the universal need for caregiver psychological support. It is recommended that future studies take into consideration the ongoing impact of pandemic-related stressors on caregivers of patients suffering from major depressive disorder.
The present study is subject to several limitations, which are outlined below. First, the cross-sectional nature of the study precluded the exploration of psychiatric disorders in caregivers throughout the course of the disease. Consequently, further longitudinal studies are warranted to elucidate the precise nature of mental health morbidity in caregivers of MDD patients, along with the associated factors that may influence these outcomes. Second, our study design involved consecutive sampling, which may have led to sampling bias. The present study concentrated on a specific psychiatric population, namely those suffering from MDD, which resulted in a question regarding the generalizability of the findings. The methodological limitations regarding cross-sectional design and sampling bias can be corroborated by seminal studies in the field, which highlight the inherent constraints of these approaches.40,41 We noted that the challenges of cross-sectional design and single-center sampling are consistently observed in the most contemporary literature. For instance, recent studies published up to 2026, such as those by Liang et al and Aydin et al, continue to rely on the above methodologies to assess caregiver burden, demonstrating that these constraints reflect the practical realities and ongoing methodological landscape of the field.42,43 Third, it is important to note that approximately 24% of the caregivers in our sample scored above the cutoff for probable major depressive disorder. Since caregiver burden and caregiver depression were both self-reported by the same individual at the same sitting, this finding has significant implications for interpreting the study’s main results. Depressed individuals are known to exhibit mood-congruent negativity in self-reports. Consequently, the positive association observed between caregiver burden and caregiver depressive symptoms may partly reflect shared method variance and conceptual overlap between subjective burden measures and depression scales. Furthermore, the coexistence of subjective burden and underlying specific mental health issues (such as personality, cognitive bias, or other psychosocial stressors) within the caregivers themselves cannot be entirely distinguished. Nevertheless, few existing studies focusing on the caregiver burden of patients with mental illnesses have taken pre-existing psychopathology, personality traits, particular circumstances, as well as social support and religious/spiritual beliefs into consideration, including the present study. Further studies incorporating these variables should be conducted to clarify these concepts. Fourth, as all subjects diagnosed with depression were in remission status, we did not consider the severity of depressive symptoms as a factor of caregiver burden. Consequently, we did not collect any explicitly depressive symptoms data and relied on disability categories as a proxy for their chronic functional impairment. Because of this methodological constraint, our study design resulted in an imbalance in variable selection, with a predominant focus on caregiver-side variables. The findings should therefore be interpreted primarily as highlighting the associations between subjective caregiver burden and the caregivers’ own mental health and sociodemographic characteristics. Finally, although the sample size met the minimum requirement estimated for testing the overall regression model using G*Power, the relatively large number of independent variables included in the multiple linear regression analyses may have limited the stability of individual regression coefficients. Therefore, the regression findings should be interpreted cautiously as exploratory associations. In addition, certain caregiver burden subdomains, particularly stigma, demonstrated relatively skewed score distributions, which may limit the suitability of standard linear modeling assumptions. Moreover, because multiple statistical comparisons were conducted without formal correction procedures, the possibility of inflated Type I error should also be considered.
Conclusion
This study hypothesized that specific sociodemographic factors and the caregivers’ own mental health status would be significantly associated with caregiving burden severity. Our findings corroborated these hypotheses, demonstrating that caregiver burden is significantly associated with the educational attainment of the caregivers and their symptoms of depression. The severity of depression was identified as the most consistent factor across a range of burden dimensions, emphasizing the pivotal role of caregivers’ own mental health in shaping their caregiving experience. These findings underscore the pressing need for targeted psychosocial support and early mental health interventions to alleviate the burden and promote well-being among this vulnerable caregiver population.
Funding Statement
This study was supported by grants from E-Da Hospital, Taiwan (grant number EDAHS114032). The funding sources had no involvement in the study design; the collection, analysis, or interpretation of the data; the writing of the report; or the submission of the paper for publication.
Data Sharing Statement
The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding authors.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Disclosure
The authors report no conflicts of interest in this work.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding authors.