Skip to main content
NCBI home page
Psychiatry, Psychology, and Law logoLink to Psychiatry, Psychology, and Law
. 2025 Oct 6;33(5):1392–1405. doi: 10.1080/13218719.2025.2546313

Caregiver burden in forensic mental health settings: social impacts on caregivers of individuals with severe mental disorders

Furkan Bahadır Alptekın a,✉, Hakan Karaağaç b, Hüseyin Şehit Burhan a, Tuğba Kara c
PMCID: PMC13618128  PMID: 42807927

Abstract

Caregivers of individuals with severe mental disorders face profound challenges, particularly when patients have criminal histories. Social functioning and perceived social support are central to caregiver burden. This cross-sectional study investigated the role of sociodemographic, illness-related, social, and support factors in 160 family caregivers of forensic inpatients. The Zarit Caregiver Burden Scale, Multidimensional Scale of Perceived Social Support and Social Adaptation Self-Evaluation Scale were used. Caregivers exposed to patient violence reported greater burden (β = −.69, p < .001). Social functioning was a strong negative predictor (β = −.43, p < .001). Family support moderated the association between social functioning and caregiver burden, amplifying its protective role, whereas perceived support alone was not a direct predictor. Overall, social functioning emerged as the strongest determinant of caregiver burden, with family support reinforcing its impact.

Keywords: caregiver burden, family support, forensic psychiatry, forensic psychology, perceived social support, severe mental disorders, social functioning

Introduction

Severe mental disorders (SMD) is an umbrella term for psychiatric disorders resulting in severe functional impairment, and it refers to schizophrenia and schizoaffective, delusional, major depressive and bipolar disorders (Regev & Josman, 2020). It affects 4% of the adult population globally (Silaule et al., 2023). Individuals with SMD face stigma, inadequate housing and lower employment and education levels, making it more challenging to navigate complex welfare, social and healthcare systems (Bellass et al., 2021).

Patients with SMD often develop a strong dependence on their caregivers due to the significant impairments associated with their conditions. Most care for individuals with SMD, particularly those with schizophrenia spectrum disorders and bipolar disorder, is provided by informal caregivers. It is estimated that 50% to 90% of them live with family members or friends (Von Kardorff et al., 2016). Also, approximately 90% of people with SMD are assisted physical and psychologically on a daily basis by family carers (Cham et al., 2022). As a result of the physical and psychological needs of people with SMD, many caregivers experience a significant amount of psychological pressure and are heavily burdened (Karaağaç, 2023; Sun et al., 2019). Caregivers frequently face limitations on their personal freedom and social interactions because of their deep commitment to providing daily emotional and financial support. This significant responsibility can lead to emotional strain, physical exhaustion, financial difficulties and a range of negative feelings, such as guilt, anger, grief and stigma (Ranjan et al., 2022). Studies indicate that caregiver burden is higher among older and female caregivers, in those with depressive symptoms, self-perceived stigma and limited social support, and where there are longer caregiving durations, more time spent with patients and patient behavioural issues (Mulud & McCarthy, 2017). Several meta-analyses have indicated a link between caregiver burden and psychological distress, including depression and anxiety (Cham et al., 2022).

Tendency to violence and criminal offences in people with SMD are also factors that increase caregiver burden (Cantekin & Ünlü, 2024). Caregivers of SMD with a crime are believed to experience an increased burden due to the intensity of SMD, involvement in criminal offences and associated legal proceedings (Vestphal et al., 2023). The lifetime rates of violent crime are notably higher among individuals with SMD, especially those with schizophrenia spectrum disorders and bipolar disorder. Research on those has identified several factors that increase the risk of violence. These include male gender, low socioeconomic status, homelessness, co-occurring substance abuse, non-adherence to treatment and the presence of positive psychotic symptoms. Some of these are related to the caregiver (Whiting et al., 2021).

For these reasons, it is vital to ease the burden on caregivers of SMD patients with criminal convictions. In this regard, improvements in social life come to the fore. Social isolation is related to the caregiver burden of schizophrenia (Vadher et al., 2020). The effect of social support on the burden of caregivers of those with bipolar disorder has also been studied (Mirhosseini et al., 2024). Low social support, family, and social dysfunction are also factors associated with the burden of mental disorders caregivers (Souza et al., 2017). In studies of caregivers for individuals with SMD, a lack of social support is the primary predictor of depression among these caregivers and significantly contributes to their burden. In contrast, having social support can alleviate caregiver burden (Sun et al., 2019).

There are different positions that a person assumes in social life, both actively and passively. Perception of social support is an important concept that evaluates the passive position of an individual in his/her social environment. This perception is related to the extent to which the individual is aware of the types of support he/she receives from his/her environment and to what extent he/she can access them. On the other hand, social functioning is a broader concept. It refers to the active position of an individual in his/her social environment. Social functioning encompasses dynamic processes such as the individual’s capacity to fulfil social roles in daily life, communicate effectively with others and maintain social responsibilities. The perception of social support and social functioning are two critical dimensions in interaction (Park & Kim, 2024; Santini et al., 2015; Saris et al., 2017).

This study investigates the impact of various sociodemographic factors, disease-related characteristics and aspects of social life – such as social functioning and perceived social support – on the burden experienced by caregivers of individuals with SMD receiving treatment in forensic services. The study’s first hypothesis is that social factors are associated with caregiver burden. The second hypothesis proposes that social functioning is a stronger predictor of caregiver burden than perceived social support. The third hypothesis is that perceived social support moderates the relationship between social functioning and caregiver burden (Figure 1).

Figure 1.

Figure 1.

Open in a new tab

Hypothesised moderation model.

Method

Sample and procedure

This cross-sectional study was conducted with family caregivers of patients with severe mental disorders who were receiving inpatient treatment at a high-security hospital between January and November 2022. Participants were recruited from the Kayseri province of Türkiye. High-security hospitals are institutions where people who are involved in criminal offences or are alleged to be involved in criminal offences in Turkey are evaluated and treated for mental disorders. According to the Turkish Penal Code, if people who commit a crime are exempt from criminal responsibility due to mental illness, they can be hospitalised and treated compulsorily (Karaağaç & Kara, 2023).

The study population includes family caregivers of patients who have been hospitalised and treated due to their severe mental disorder and the crimes they committed. People who were over 18 years of age, volunteered to participate in the study and were caring for relatives diagnosed with schizophrenia spectrum disorder or bipolar disorder and subjected to compulsory inpatient treatment due to their crime were included. Those who had a severe mental illness themselves or whose patient had a diagnosis of mental retardation or psychosis due to substance use were excluded. In the sources we referenced, we identified schizophrenia, schizoaffective disorder, delusional disorder and bipolar disorder as severe mental disorders. We chose not to include intellectual disability in our analysis, as its onset differs from the other conditions, which could complicate interpretation. Additionally, we did not consider substance-induced psychosis, due to the numerous variables that are difficult to control, such as the type of substance used and frequency of use. A priori power analysis was conducted using G*Power 3.1 to determine the required sample size for a multiple linear regression analysis. To detect a medium effect size (f2 = .15), with a significance level of α = .05, statistical power of .95, and eight predictor variables, the analysis indicated that a minimum sample size of 89 participants was required. To account for potential missing data, an additional 15% of participants were recruited, resulting in a final minimal sample size of 103 caregivers. A total population sampling method was employed. During the study period, the caregiver of each patient who was hospitalised due to a serious mental disorder associated with criminal behaviour was assessed for eligibility. All caregivers who met the inclusion criteria were invited to participate, and a total of 214 caregivers were reached. Among them, 48 individuals declined to participate, and six were excluded due to incomplete data. Thus, the final sample consisted of 160 caregivers (response rate = 74.8%).

Materials

The Sociodemographic Information Form gathers details about participants, including their age, sex, occupation and educational background. Additionally, participants were asked how long they had been providing care, the diagnosis of the person and the relationship with whom they were caring, and whether they had experienced any incidents of violence by the patient.

The Zarit Burden Interview (ZBI) was developed by Zarit et al. in 1980 to assess the distress experienced by caregivers (Zarit et al., 1980). The scale, which is filled out as a self-report, consists of 22 items on a 5-point Likert scale. The instrument has demonstrated excellent internal consistency, with Cronbach’s alpha values ranging from .85 to .93. The authors assessed its validity by correlating the total score with that of the Brief Symptom Inventory, obtaining a correlation coefficient of r = .41, along with the subscales. İnci and Erdem demonstrated the validity and reliability of the Turkish version (İnci & Erdem, 2006). On a single-dimensional scale, increasing scores indicate an increasing caregiver burden. The Turkish version of this scale achieved a Cronbach’s alpha value of .95.

The Multidimensional Scale of Perceived Social Support (MSPSS) was developed by Zimet et al. (Zimet et al., 1990), and Eker and Arkar conducted the validity and reliability study of the Turkish version (Eker & Arkar, 1995). It is a self-report scale consisting of 12 items on a 7-point Likert type. It evaluates perceived social support in three sub-dimensions: family, friends and significant others. Increasing scores indicate an increased perception of social support.

The Social Adaptation Self-Evaluation Scale (SASS) assesses changes in overall social functioning. The original form comprises 21 items that use a 4-point Likert scale to evaluate different aspects of an individual’s life, such as work, relationships with family and friends, intellectual pursuits, hobbies, satisfaction with personal performance and the ability to manage their environment (Bosc et al., 1997). In the Turkish version, the scores of 20 questions are summed to evaluate the scale as a single factor (Akkaya et al., 2008). Higher scores indicate increased social functioning.

The scales were completed as a self-report under a psychologist’s supervision. Interpreter support was provided when communication was necessary.

Statistics

All statistical analyses were performed using Jamovi Version 2.3.28.0. We conducted descriptive statistical analysis to describe the demographic background of all participants and the frequencies of key variables. We calculated the mean and standard errors for continuous variables and frequencies and percentages for categorical variables. Associations between the main study variables were initially examined using Pearson correlation. After controlling the sociodemographic data, multiple regression analysis was applied to test factors predicting caregiver burden. To assess potential multicollinearity, variance inflation factor (VIF) values were calculated for each independent variable. All VIF values remained below 10 (ranging from 1.07 to 7.81), indicating an acceptable level of multicollinearity. Moderation analysis was performed to examine whether perceived social support influences the strength or direction of the relationship between social functioning and caregiver burden. We examined the main effects of social functioning and social support and their interaction effect on caregiver burden. Conditional effects were probed at the moderator’s low (–1 SD), mean and high (+1 SD) levels to interpret the significant interaction terms. All assumptions for regression analysis, including linearity and homoscedasticity, were checked prior to conducting the analysis.

Results

Sample characteristics

The average age of the participants was 49.0 years (SD = 14.1), while the average age of the patients they cared for was 39.2 years (SD = 13.4). Out of the caregivers, 79 were women (49.4%), and the caregiver burden was higher for women (M = 75.4, SD = 22.2) than for men (M = 68.1, SD = 22.1), t(158) = 2.06, p = .041. Women also spent more time with their patients (M = 13.6 vs. 9.7, SD = 5.64 vs. 5.55); t(158) = 4.46, p < .001. A total of 43.8% (n = 70) of the participants were the parents of the patients, followed by siblings (n = 31), spouses (n = 28) and children (n = 20) as caregivers.

More than half of the participants (53.1%, n = 85) reported experiencing violence from the patients they cared for. Caregiver burden was significantly higher in caregivers who were subjected to violence by their patients (M = 81.4, SD = 18.09) than in those who were not subjected to violence (M = 60.7, SD = 21.74), t(145) = 6.50, p < .001. Participants stated that 33.1% of the patients were diagnosed with schizophrenia, 27.5% with atypical psychosis, 26.9% with bipolar disorder and 0.6% with schizoaffective disorder. Additionally, 11.9% did not know the patient’s diagnosis (Table 1).

Table 1.

Demographic variables.

    n % m SD
Age of caregivers   160   49.0 14.1
Age of patients with SMD   160   39.2 13.4
Sex of caregivers Male 81 50.6    
Female 79 49.4
Educational level Illiterate 9 5.6    
Primary education 76 47.5
High school 53 33.1
  University 22 13.8    
Family relationship with the patient Spouse 28 17.5    
Sibling 31 19.4
Child 20 12.5
Parents 70 43.8
Other relatives 19 11.9
Diagnosis of the patient (according to caregiver) Schizophrenia 53 33.1    
Atypical psychosis 44 27.5
Bipolar disorder 43 26.9
Sch.aff. disorder 1 0.6
  Unknown 11 9.6    
Violence from the patients Yes 85 53.1    
No 75 46.9
Open in a new tab

Note: SMD = severe mental disorder; sch.aff. disorder = schizoaffective disorder.

Conceptual variables

Table 2 shows the correlations, means and standard deviations of the three measures in the current sample. The mean score of ZBI was 71.7 (SD = 22.4). Mean scores were: MSPSS Family 21.6 (SD = 6.0), MSPSS Friends 13.1 (SD = 6.71), MSPSS Significant Others 12.48 (SD = 6.49) and SASS 36.1 (SD = 9.34). All scales and subscales were significantly correlated.

Table 2.

Bivariate correlation of continuous variables.

  M SD Possible min–max 1 2 3 4 5 6 7 8
1. Age of caregivera 49.0 14.1   —              
2. Age of patientsa 39.2 13.4   −.090 —            
3. Time spent togethera 12.3 8.07   .131 .050 —          
4. ZBI 71.7 22.4 22–110 .233** −.064 .141 —        
5. MSPSS–Family 21.6 6.00 3–21 −.086 .025 −.101 −.366*** —      
6. MSPSS–Friends 13.1 6.71 3–21 −.265*** .066 .002 −.425*** .465*** —    
7. MSPSS–Others 12.8 6.49 3–21 −.241** .075 .042 −.436*** .463*** .930*** —  
8. SASS 36.1 9.34 0–60 −.326*** .166* −.103 −.600*** .514*** .642*** .635*** —
Open in a new tab

Note: Assessed with Pearson correlation.

ZBI = Zarit Burden Interview (Caregiver Burden); MSPSS = Multidimensional Scale of Perceived Social Support (Perceived Social Support); SASS = Social Adaptation Self-Evaluation Scale (Social Functioning).

aIn years.

*p < .05. **p < .01. ***p < .001.

Regression model

To control for the possible effect of sociodemographic and disease-related factors on caregiving burden, we enter these variables in the first block (age and sex of participants, caregiving duration, experiencing violence from the patients they cared for). In the second step we enter the perceived social support variables (MSPSS Family, MSPSS Friends and MSPSS Significant Others). In the third step we enter the social functioning (SASS). Before analysis we checked the assumptions of multicollinearity and normality. In the Kolmogorov–Smirnov test performed to evaluate normality, the p value was .237. VIF values ​​used to assess multicollinearity ranged from 1.08 to 7.88. R2 for first block was .274, for second block .406 and third block .495. Second block values explain an additional 13.1% of the variance in caregiver burden (ΔR2 = .131, p < .001), and third block values explain an additional 8.9% of the variance in caregiver burden (ΔR2 = .089, p < .001). In Model 2 and Model 3, predictive effect of perceived social support (MSPSS Family, MSPSS Friends and MSPSS Significant Others) is statistically insignificant. Of these two variables in Model 3, experiencing violence from the patients they cared for makes the largest contribution (β = −.69, p < .001); social functioning (SASS) also made a statistically significant contribution (β = −.43, p < .001; Table 3).

Table 3.

Hierarchical regression analysis for predicting caregiver burden.

Model R2 ΔR2
p 		Variable β p
1 .274   Constant   <.001
  Age .219 .002
  Sexa −.206 .142
  Caregiving duration .035 .615
  Violence from the patientsb −.865 <.001
2 .406 .131
<.001		 Constant   <.001
Age .130 .054
Sexa −.159 .238
Caregiving duration .031 .630
Violence from the patientsb −.781 <.001
Social support from family −.088 .241
Social support from friends −.079 .647
Social support from significant others −.251 .150
3 .495 .089
<.001		 Constant   <.001
Age .05 .419
Sexa −.133 .284
Caregiving duration .036 .550
Violence from the patientsb −.690 <.001
  Social support from family .014 .842
  Social support from friends .032 .842
  Social support from significant others −.153 .346
  Social functioning −.430 <.001
Open in a new tab

a1= women, 2 = men.

b1= Yes, 2= No.

The moderating role of social support from family on the relationship between caregiver burden and social functioning

Social support from friends and significant others did not moderate the relationship between social functioning and caregiver burden. However, the perception of social support from family did act as a moderator (Table 4). As illustrated in Figure 2, social functioning and caregiver burden have a negative relationship. The moderator variable – perceived social support from family – impacts this relationship at all three levels. The significant interaction term (Social Functioning × Social Support from Family) indicates that the moderator enhances the connection between social functioning and caregiver burden. Specifically, at higher levels of perceived social support, the protective effect of social functioning on caregiver burden is more pronounced (see also Table 5).

Table 4.

Moderation estimates.

  Estimate SE Z p
Social functioning −1.249 0.149 −8.38 <.001
Social support from family −0.554 0.232 −2.39 .017
Social Functioning × Social Support from Family −0.056 0.025 −2.22 .026
Open in a new tab

Figure 2.

Figure 2.

Open in a new tab

Moderation effect of perceived social support from family on the effects of social functioning on caregiver burden.

Table 5.

Simple slope estimates.

  Estimate SE Z p
Average −1.249 0.151 −8.25 <.001
Low (–1 SD) −0.914 0.216 −4.23 <.001
High (+1 SD) −1.585 0.214 −7.42 <.001
Open in a new tab

Note: Shows the effect of the predictor (social functioning) on the dependent variable (caregiver burden) at different levels of the moderator (perceived social support from family).

Discussion

Examining sociodemographic and disease effects

In our study, we found that caregiver burden scores were higher for women. This observation aligns with existing literature regarding caregivers of both physical and psychiatric patients (Cham et al., 2022; Choi et al., 2024; Peng et al., 2022; Rahmani et al., 2022). The increased burden among women may be attributed to psychological and social factors, as well as the greater average caregiving time that women typically contribute throughout the day, as demonstrated in our sample. Additionally, greater dissatisfaction with fulfilling the caregiver role, heightened concerns about the emotional wellbeing of those they care for and the greater likelihood of providing personal care assistance, which can lead to more intense physical and emotional strain, may also be effective factors (Sharma et al., 2016).

In our study, a significant portion of the caregivers were the patient’s parents. Similar results are evident in studies conducted on caregivers of psychiatric patients (Estrada‐Fernández et al., 2022; Karambelas et al., 2022). The fact that psychiatric patients, especially those with schizophrenia, need care at relatively earlier ages and that their marriage rates are low may explain this situation (Mina, 2019).

In our study, over half of the participants reported experiencing violence from their patients. The results showed that caregivers who faced violence had a significantly higher burden. Additionally, experiencing violence emerged as one of the two main factors influencing caregiver burden. A study by Labrum et al. (2021) on violence committed by individuals with serious mental illnesses against family caregivers found that these caregivers frequently encounter violence when they are alone at home with their relatives (Labrum et al., 2021). This situation can have a significantly negative impact on the wellbeing of the caregivers. Alyafei et al. identified domestic abuse and violence as risk factors contributing to caregiver burden in a review of qualitative studies on the experiences of caregivers for individuals with severe mental disabilities in Middle Eastern societies (Alyafei et al., 2021). Another review of the impact of violence by psychotic patients on caregivers found that 14 studies established a positive correlation between patient violence and carer burden (Onwumere et al., 2018). The same study indicates that women are at a higher risk of experiencing violence from their patients, similar to findings in our research. Given the impact of violence on caregiver burden, this could be a contributing factor to the elevated caregiver burden observed in women within our study. Although it is expected that a patient’s violent behaviour will increase the caregiver’s burden, several important questions remain unanswered. These include the nature of the violence, its duration, whether it occurs repeatedly and whether the person subjected to violence is the only caregiver. Each of these factors may significantly impact the relationship between violence and caregiver burden.

Social functioning versus perceived social support

Among perceived social support from family, friends and significant others, only family support affects the caregiver’s burden. However, family support loses its statistical significance when other factors are included in the regression analysis. Across studies, social support shows an inconsistent relationship with distress (del-Pino-Casado et al., 2018; Rivera-Rivera et al., 2021). Cohen et al.’s (2004) approach provides a valuable perspective to explain these contradictory results. Accordingly, social support has two dimensions: perceived and received social support. Perceived social support is ‘an individual’s perception of the amount and quality of support they receive from their social network’, while received social support is defined as ‘the objective quantity of help and support people receive from their social networks’ (Ong et al., 2018, p. 2). Results of the meta-analysis by del-Pino-Casado et al. (2018) using the perceived–received social support approach, suggest that perceived social support may be a good predictor of subjective burden, which is inconsistent with our study.

In our study, we found that after controlling for social functioning, the correlation between perceived social support and caregiver burden was not statistically significant. This suggests that we need to consider social impact more comprehensively. Whether it is received or perceived, social support highlights the passive role of individuals in their social lives. In contrast, social functioning encompasses both the active and passive roles a person plays in their social interactions. Therefore, the active involvement of the caregiver in social life has a more significant impact on caregiver burden than the perception of passive social support. This result, which emphasises the social functioning of the caregiver, keeps the person in a more active position and directs them towards more promising solutions to cope with the caregiver burden. Tziaka et al. also published a systematic review of caregivers of stroke survivors, emphasising the impact of social functioning on caregiver burden (Tziaka et al., 2024). In their study, Rodakowski et al. showed significant effects of both social integration and social support on caregiver burden in patients with spinal cord injury in their study (Rodakowski et al., 2012). The literature has focused on the impact of social support on caregiver burden. Although there are no significant data in the literature on the effects of active and passive positions in social life on caregiver burden, active and passive attitudes towards social life have a long-standing place in the literature (Hereford et al., 1967; Snider et al., 1968). Some studies offer a similar approach to social life, albeit in different contexts (Woods et al., 2021). The results of our study encourage a broader view of the social domain and suggest that more studies should focus on social functioning. It also highlights the importance of an individual’s active participation in social life to alleviate the burden on caregivers.

The moderation test reveals that perceived social support from family strengthens the relationship between social functioning and caregiver burden. In particular, when perceived social support is high, the positive effect of social functioning on reducing caregiver burden is more significant. Some studies show that social support moderates the effects of different factors such as patient characteristics and caregiving duration on caregiver burden and stress (George et al., 2020; Liu et al., 2022; Wang et al., 2018; Xu et al., 2021). Our study reveals a significant moderation relationship that has not been previously recognised. Not only does social support enhance social functioning, but it also magnifies the positive impact of social functioning on caregiver burden. In contrast, low levels of social support weaken the protective influence of social functioning. These findings emphasise the family’s vital role as a source of social support. To effectively reduce caregiver burden, it’s crucial to incorporate methods that bolster social functionality while also actively involving other family members in the support network.

The study has some limitations. First, we gathered data using self-report questionnaires, which are subjective measures. So, there is a potential risk of measurement bias, including social desirability and recall bias. Measurement error cannot be entirely ruled out, especially given the reliance on participants’ subjective interpretations of questionnaire items. Second, the study was structured as a cross-sectional survey instead of a longitudinal one, so the results need to be supported by longitudinal studies to be generalisable. The fact that the sample was drawn from a specific forensic mental health setting also limits the generalisability of the findings to broader caregiver groups. Third, although there was no multicollinearity among the scales, the scale we used to assess social functioning (SASS) included some questions potentially assessing perceived social support (Item 12: How often do people in your social circle seek contact with you?; Item 18: How often do you feel rejected, excluded from your circle?). Measurement tools that more specifically assess the active position of caregivers in social life will increase the quality of the study. Fourth, the nature of the symptoms could influence caregiver burden; however, one limitation of the study was that participants did not document the symptoms of the patients for whom they provided care. Future research should consider using larger, more diverse samples and incorporating multiple data sources to increase robustness and external validity.

Conclusion

Caregiver burden is a significant issue for those supporting patients with severe mental disorders, particularly women and those who experience violence from patients in forensic settings. This highlights the importance of targeted interventions at the individual level, including psychoeducation, personalised counselling and stress management programmes, to enhance social functioning. At the institutional level, especially within forensic psychiatric services, it is essential to implement structured support systems for caregivers. This includes regular assessments, peer support mechanisms and family-inclusive care planning. At the policy level, the strong link between caregiver burden and violence from patients highlights the need for national strategies. These should incorporate legal protections, financial assistance programmes and the formal inclusion of caregiver wellbeing in mental health policies and services. Additionally, strengthening family-based social support structures can enhance social functioning, thereby reducing caregiver burden.

Funding Statement

The authors received no financial support for the research, authorship or publication of this study.

Ethical standards

Declaration of conflicts of interest

Furkan Bahadır Alptekin has declared no conflicts of interest.

Hakan Karaağaç has declared no conflicts of interest.

Hüseyin Şehit Burhan has declared no conflicts of interest.

Tuğba Kara has declared no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Kayseri City Training and Research Hospital Ethics Committee (approval number: 557) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study. All participants were provided with mental health resources.

Author contributions

FBA: conceptualisation, methodology, formal analysis, writing – original draft, writing – review and editing. HK: conceptualisation, investigation, data curation, review and editing. HŞB: conceptualisation, formal analysis, review and editing. TK: resources, investigation, supervision, project administration.

References

  1. Akkaya, C., Sarandöl, A., Esen Danaci, A., Sivrioğlu, E. Y., Kaya, E., & Kirli, S. (2008). [Reliability and validity of the Turkish version of the Social Adaptation Self-Evaluation Scale (SASS)]. Turk Psikiyatri Dergisi = Turkish Journal of Psychiatry, 19(3), 292–299. [PubMed] [Google Scholar]
  2. Alyafei, A. H., Alqunaibet, T., Mansour, H., Ali, A., & Billings, J. (2021). The experiences of family caregivers of people with severe mental illness in the Middle East: A systematic review and meta-synthesis of qualitative data. PLoS One, 16(7), e0254351. 10.1371/journal.pone.0254351 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Bellass, S., Lister, J., Kitchen, C. E. W., Kramer, L., Alderson, S. L., Doran, T., Gilbody, S., Han, L., Hewitt, C., Holt, R. I. G., Jacobs, R., Prady, S. L., Shiers, D., Siddiqi, N., & Taylor, J. (2021). Living with diabetes alongside a severe mental illness: A qualitative exploration with people with severe mental illness, family members and healthcare staff. Diabetic Medicine, 38(7), e14562. 10.1111/dme.14562 [DOI] [PubMed] [Google Scholar]
  4. Bosc, M., Dubini, A., & Polin, V. (1997). Development and validation of a social functioning scale, the Social Adaptation Self-evaluation Scale. European Neuropsychopharmacology, 7 (S1), S57–S70. discussion S71-73. 10.1016/s0924-977x(97)00420-3 [DOI] [PubMed] [Google Scholar]
  5. Cantekin, Ö. F., & Ünlü, S. İ. (2024). The relationship between burnout and violence tendencies of caregivers of patients with schizophrenia. Unnes Journal of Public Health, 13(2), 23–35. [Google Scholar]
  6. Cham, C. Q., Ibrahim, N., Siau, C. S., Kalaman, C. R., Ho, M. C., Yahya, A. N., Visvalingam, U., Roslan, S., Abd Rahman, F. N., & Lee, K. W. (2022). Caregiver burden among caregivers of patients with mental ıllness: A systematic review and meta-analysis. Healthcare, 10(12), 2423. 10.3390/healthcare10122423 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Choi, J. Y., Lee, S. H., & Yu, S. (2024). Exploring factors ınfluencing caregiver burden: A systematic review of family caregivers of older adults with chronic ıllness in local communities. Healthcare, 12(10), 1002. 10.3390/healthcare12101002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Cohen, S. (2004). Social relationships and health. The American Psychologist, 59(8), 676–684. 10.1037/0003-066X.59.8.676 [DOI] [PubMed] [Google Scholar]
  9. del-Pino-Casado, R., Frías-Osuna, A., Palomino-Moral, P. A., Ruzafa-Martínez, M., & Ramos-Morcillo, A. J. (2018). Social support and subjective burden in caregivers of adults and older adults: A meta-analysis. PLoS One, 13(1), e0189874. 10.1371/journal.pone.0189874 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Eker, D., & Arkar, H. (1995). Factorial structure, validity, and reliability of the multidimensional scale of perceived social support. Turk Psikoloji Dergisi, 10(34), 45–55. [Google Scholar]
  11. Estrada‐Fernández, M. E., Gil‐Lacruz, M., Gil‐Lacruz, A. I., & Viñas‐López, A. (2022). The impact of community care: Burden and quality of life of the informal caregivers of patients with severe mental disorder. Journal of Community Psychology, 50(1), 487–501. 10.1002/jcop.22594 [DOI] [PubMed] [Google Scholar]
  12. George, E. S., Kecmanovic, M., Meade, T., & Kolt, G. S. (2020). Psychological distress among carers and the moderating effects of social support. BMC Psychiatry, 20(1), 154. 10.1186/s12888-020-02571-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Hereford, C. F., Stenning, N. S., & Natalicio, L. (1967). A cross-cultural comparison of the active-passive dimension of social attitudes. Revista Interamericana de Psicología/Interamerican Journal of Psychology, 1(1), 430. 10.30849/rip/ijp.v1i1.430 [DOI] [Google Scholar]
  14. İnci, F., & Erdem, M. (2006). Bakim verme yükü ölçeği’nin türkçe’ye uyarlanmasi geçerlilik ve güvenilirliği. Anadolu Hemşirelik ve Sağlık Bilimleri Dergisi, 11(4), 85–95. [Google Scholar]
  15. Karaağaç, H. (2023). Psikososyal Boyutlarıyla Adli Psikiyatri Deneyimler Işığında Tedavi Sonrası Hayat. Efe Akademi Yayınları. [Google Scholar]
  16. Karaağaç, H., & Kara, T. (2023). High Security Forensic Psychiatry Hospitals in Türkiye current status and future challenges: Traditional review. Turkiye Klinikleri Journal of Forensic Medicine and Forensic Sciences, 20(2), 149–156. 10.5336/forensic.2023-95917 [DOI] [Google Scholar]
  17. Karambelas, G. J., Filia, K., Byrne, L. K., Allott, K. A., Jayasinghe, A., & Cotton, S. M. (2022). A systematic review comparing caregiver burden and psychological functioning in caregivers of individuals with schizophrenia spectrum disorders and bipolar disorders. BMC Psychiatry, 22(1), 422. 10.1186/s12888-022-04069-w [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Labrum, T., Zingman, M. A., Nossel, I., & Dixon, L. (2021). Violence by persons with serious mental ıllness toward family caregivers and other relatives: A review. Harvard Review of Psychiatry, 29(1), 10–19. 10.1097/HRP.0000000000000263 [DOI] [PubMed] [Google Scholar]
  19. Liu, Z., Sun, W., Chen, H., Zhuang, J., Wu, B., Xu, H., Li, P., Chen, X., Li, J., & Yin, Y. (2022). Caregiver burden and its associated factors among family caregivers of persons with dementia in Shanghai, China: A cross-sectional study. BMJ Open, 12(5), e057817. 10.1136/bmjopen-2021-057817 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Mina, S. (2019). Predictors of marriage in psychiatric ıllness: A review of literature. Journal of Psychiatry and Psychiatric Disorders, 03(01), 58. 10.26502/jppd.2572-519X0058 [DOI] [Google Scholar]
  21. Mirhosseini, S., Parsa, F. I., Gharehbaghi, M., Minaei-Moghadam, S., Basirinezhad, M. H., & Ebrahimi, H. (2024). Care burden and associated factors among caregivers of patients with bipolar type I disorder. BMC Primary Care, 25(1), 321. 10.1186/s12875-024-02583-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Mulud, Z. A., & McCarthy, G. (2017). Caregiver burden among caregivers of ındividuals with severe mental ıllness: Testing the moderation and mediation models of resilience. Archives of Psychiatric Nursing, 31(1), 24–30. 10.1016/j.apnu.2016.07.019 [DOI] [PubMed] [Google Scholar]
  23. Ong, H. L., Vaingankar, J. A., Abdin, E., Sambasivam, R., Fauziana, R., Tan, M. E., Chong, S. A., Goveas, R. R., Chiam, P. C., & Subramaniam, M. (2018). Resilience and burden in caregivers of older adults: Moderating and mediating effects of perceived social support. BMC Psychiatry, 18(1), 27. 10.1186/s12888-018-1616-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Onwumere, J., Zhou, Z., & Kuipers, E. (2018). Informal caregiving relationships in psychosis: Reviewing the ımpact of patient violence on caregivers. Frontiers in Psychology, 9, 1530. 10.3389/fpsyg.2018.01530 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Park, H., & Kim, J. (2024). Perceived social position, active engagement with life, and depressive symptoms among older adults. Social Science & Medicine, 345, 116716. 10.1016/j.socscimed.2024.116716 [DOI] [PubMed] [Google Scholar]
  26. Peng, M.-M., Xing, J., Tang, X., Wu, Q., Wei, D., & Ran, M.-S. (2022). Disease-related risk factors for caregiver burden among family caregivers of persons with schizophrenia: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 19(3), 1862. 10.3390/ijerph19031862 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Rahmani, F., Roshangar, F., Gholizadeh, L., & Asghari, E. (2022). Caregiver burden and the associated factors in the family caregivers of patients with schizophrenia. Nursing Open, 9(4), 1995–2002. 10.1002/nop2.1205 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Ranjan, L. K., Gupta, P. R., Kiran, M., & Singh, N. K. (2022). Family care burden and its association with psychological distress among caregivers of chronic patients with schizophrenia. Journal of Public Health and Primary Care, 3(3), 81–85. 10.4103/jphpc.jphpc_16_22 [DOI] [Google Scholar]
  29. Regev, S., & Josman, N. (2020). Evaluation of executive functions and everyday life for people with severe mental illness: A systematic review. Schizophrenia Research. Cognition, 21, 100178. 10.1016/j.scog.2020.100178 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Rivera-Rivera, J. N., Badour, C. L., & Burris, J. L. (2021). The association between psychological functioning and social support and social constraint after cancer diagnosis: A 30-day daily diary study. Journal of Behavioral Medicine, 44(3), 355–367. 10.1007/s10865-021-00200-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Rodakowski, J., Skidmore, E. R., Rogers, J. C., & Schulz, R. (2012). Role of social support in predicting caregiver burden. Archives of Physical Medicine and Rehabilitation, 93(12), 2229–2236. 10.1016/j.apmr.2012.07.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Santini, Z. I., Koyanagi, A., Tyrovolas, S., Mason, C., & Haro, J. M. (2015). The association between social relationships and depression: A systematic review. Journal of Affective Disorders, 175, 53–65. 10.1016/j.jad.2014.12.049 [DOI] [PubMed] [Google Scholar]
  33. Saris, I. M. J., Aghajani, M., Van Der Werff, S. J. A., Van Der Wee, N. J. A., & Penninx, B. W. J. H. (2017). Social functioning in patients with depressive and anxiety disorders. Acta Psychiatrica Scandinavica, 136(4), 352–361. 10.1111/acps.12774 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Sharma, N., Chakrabarti, S., & Grover, S. (2016). Gender differences in caregiving among family—Caregivers of people with mental illnesses. World Journal of Psychiatry, 6(1), 7–17. 10.5498/wjp.v6.i1.7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Silaule, O., Nkosi, N. G., & Adams, F. (2023). Extent of caregiver burden among informal caregivers of persons with severe mental disorders in rural South Africa. Rural and Remote Health, 23(2), 7509. 10.22605/RRH7509 [DOI] [PubMed] [Google Scholar]
  36. Snider, J. G., Snider, J. A., & Nichols, K. E. (1968). Active-passive Social Attitudes toward Self and Ideal-Self in Children in Canada and the United States. The Journal of Social Psychology, 76(1), 135–136. 10.1080/00224545.1968.9919836 [DOI] [PubMed] [Google Scholar]
  37. Souza, A. L. R., Guimarães, R. A., De Araújo Vilela, D., De Assis, R. M., De Almeida Cavalcante Oliveira, L. M., Souza, M. R., Nogueira, D. J., & Barbosa, M. A. (2017). Factors associated with the burden of family caregivers of patients with mental disorders: A cross-sectional study. BMC Psychiatry, 17(1), 353. 10.1186/s12888-017-1501-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Sun, X., Ge, J., Meng, H., Chen, Z., & Liu, D. (2019). The ınfluence of social support and care burden on depression among caregivers of patients with severe mental ıllness in rural areas of Sichuan, China. International Journal of Environmental Research and Public Health, 16(11), 1961. 10.3390/ijerph16111961 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Tziaka, E., Tsiakiri, A., Vlotinou, P., Christidi, F., Tsiptsios, D., Aggelousis, N., Vadikolias, K., & Serdari, A. (2024). A holistic approach to expressing the burden of caregivers for stroke survivors: A systematic review. Healthcare, 12(5), 565. 10.3390/healthcare12050565 [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Vadher, S., Desai, R., Panchal, B., Vala, A., Ratnani, I. J., Rupani, M. P., & Vasava, K. (2020). Burden of care in caregivers of patients with alcohol use disorder and schizophrenia and its association with anxiety, depression and quality of life. General Psychiatry, 33(4), e100215. 10.1136/gpsych-2020-100215 [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Vestphal, T. K., Gildberg, F. A., Jørgensen, R., Rowaert, S., & Tingleff, E. B. (2023). Experiences of family caregivers in forensic mental health care – A qualitative evidence synthesis. Journal of Psychiatric and Mental Health Nursing, 30(4), 663–678. 10.1111/jpm.12910 [DOI] [PubMed] [Google Scholar]
  42. Von Kardorff, E., Soltaninejad, A., Kamali, M., & Eslami Shahrbabaki, M. (2016). Family caregiver burden in mental illnesses: The case of affective disorders and schizophrenia – a qualitative exploratory study. Nordic Journal of Psychiatry, 70(4), 248–254. 10.3109/08039488.2015.1084372 [DOI] [PubMed] [Google Scholar]
  43. Wang, Z., Ma, C., Han, H., He, R., Zhou, L., Liang, R., & Yu, H. (2018). Caregiver burden in Alzheimer’s disease: Moderation effects of social support and mediation effects of positive aspects of caregiving. International Journal of Geriatric Psychiatry, 33(9), 1198–1206. 10.1002/gps.4910 [DOI] [PubMed] [Google Scholar]
  44. Whiting, D., Lichtenstein, P., & Fazel, S. (2021). Violence and mental disorders: A structured review of associations by individual diagnoses, risk factors, and risk assessment. The Lancet. Psychiatry, 8(2), 150–161. 10.1016/S2215-0366(20)30262-5 [DOI] [PubMed] [Google Scholar]
  45. Woods, A., Solomonov, N., Liles, B., Guillod, A., Kales, H. C., & Sirey, J. A. (2021). Perceived social support and ınterpersonal functioning as predictors of treatment response among depressed older adults. The American Journal of Geriatric Psychiatry, 29(8), 843–852. 10.1016/j.jagp.2020.12.021 [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Xu, L., Liu, Y., He, H., Fields, N. L., Ivey, D. L., & Kan, C. (2021). Caregiving intensity and caregiver burden among caregivers of people with dementia: The moderating roles of social support. Archives of Gerontology and Geriatrics, 94, 104334. 10.1016/j.archger.2020.104334 [DOI] [PubMed] [Google Scholar]
  47. Zarit, S. H., Reever, K. E., & Bach-Peterson, J. (1980). Relatives of the ımpaired elderly: Correlates of feelings of burden. The Gerontologist, 20(6), 649–655. 10.1093/geront/20.6.649 [DOI] [PubMed] [Google Scholar]
  48. Zimet, G. D., Powell, S. S., Farley, G. K., Werkman, S., & Berkoff, K. A. (1990). Psychometric characteristics of the multidimensional scale of perceived social support. Journal of Personality Assessment, 55(3-4), 610–617. 10.1080/00223891.1990.9674095 [DOI] [PubMed] [Google Scholar]

Articles from Psychiatry, Psychology, and Law are provided here courtesy of Taylor & Francis

RESOURCES