Mohammed T. Abou-Saleh

758 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYhome, following institutionalization, and when the care recipientdies 20,41,66,83–85 .DepressionDepressive symptoms are among the most frequently examinedmental health effects on family caregivers of persons withdementia. Several studies document a greater prevalence ofdepression among caregivers of persons with dementia, comparedto other age and gender group norms and persons who are notcaregiving 43,86–88 .Prevalence rates of depressive symptomatology among caregiversrange from 30% 87 to 46% among community caregivers 86 .Moreover, depression among caregivers is associated with intensityof their reactions to the patients’ memory and behaviorproblems 89,90 and to other adverse outcomes, such as increasedphysical burden 36 , subjective burden 91–93 , and use of psychotropicmedications 15,65 .Depression is also noted to be greater among females thanmales 10 and appears to increase over time among residentialcaregivers and decrease over time following institutionalizationand bereavement 83,87 . However, younger spouse caregivers werefound to have higher levels of depression than older spouses in astudy of residential and institutional caregiving 94 . There werepositive relationships between depression and health status anddepression and days unable to work among residential caregivers,but only between physical health characteristics and health statusamong the institutional spouse caregivers, and no significantdifference in depression between genders. Compared to noncaregivingmen, male spouse caregivers have been shown to havehigher levels of depression, respiratory symptoms and poorerhealth habits, but the groups did not differ on other measures ofphysical and mental health 95 .Although no subjects were clinically depressed, Wright 81 foundspouse caregivers of demented persons to have significantlygreater dysphoric moods than a comparison group of noncaregivingspouses, with sadness of subsequently widowed spousessignificantly greater than for non-widowed spouses. Widowedspouses also had poorer health outcomes over time and usedfewer positive coping strategies, regardless of whether they placedtheir loved one in an institution.AnxietySeveral investigators incorporated self-report measures of anxietyinto their studies of depression. Mohide et al. 96 found that 22/23individuals found to have significant symptoms of depression alsoreported significant symptoms of anxiety. Similarly, Vitaliano etal. 30 found 35.4% of their sample to have significant symptoms ofanxiety. Neundorfer 93 reported much lower rates of both anxiety(15%) and depression (25%) among her sample of caregivers,although their scores were somewhat higher than populationnorms for elderly individuals.Overall, there is strong evidence suggesting that caregiversexhibit higher levels of psychiatric symptomatology than comparisongroups. Yet caution must be exercised when interpreting thegeneralizability of these findings, since many of the samples maybe biased toward the more distressed members of the caregivingcommunity. For example, the majority of caregivers are recruitedfrom local chapters of the Alzheimer’s Association, caregiversupport groups, or through referrals by healthcare professionals.Individuals who have little difficulty with the caregiving role orwho are so distressed or constrained that they are unable toparticipate in supportive programs or visit healthcare professionalsmay be underrepresented in research.Some authors have also questioned the clinical significanceof psychiatric symptoms reported in caregiver distress studies.There remains a criterion problem of distinguishing normaldistress from psychiatric illness 84 . Transient periods of grief,despair, helplessness and hopelessness may be much morecommon than a diagnosable depression among family caregivers.Becker and Morissey 84 argue that the severe andchronic stressors associated with dementia caregiving areunlikely to precipitate a major depressive disorder, except inpredisposed individuals. They suggest that the depressive-likesymptoms among caregiving spouses should be categorizedunder Code V: Conditions Not Due to a PsychiatricDisorder 84 . This view is consistent with the conclusion reachedby Fitting et al. 97 who state: ‘‘It is our impression that mostcaregivers reporting depressive symptomatology are experiencinga ‘transient dysphoric mood’ and not major depression’’(p. 250).To summarize, the literature on mental health outcomes ofcaregiving is suggestive but not conclusive 98 . There is strongevidence for increased symptom reports for depression, anxietyand increased psychotropic drug use among caregivers in thesestudies, as well as support for increased clinical psychiatric illnessamong some caregivers.Physical Health OutcomesMost of the literature examining the physical effects ofcaregiving has used one or more indicators of caregiver health:(a) self-reported health status; (b) self-reported incidence ofillness-related symptoms; (c) self-reported utilization of healthcareservices; (d) self-reported medication use; and (e) biologicalindicators as a measure of susceptibility to disease. Reportedpredictors of poor physical health outcomes for caregiversinclude older age, being a spouse rather than adult child orother relative, and being female rather than male 15,79 . Interestingly,a relationship between the positive aspects of caregivingand physical health has also been reported. Emotional uplifts infamily members with coronary heart disease (CHD), who arecaring for persons with dementia, mediates the severity ofmetabolic signs that predict CHD 99 .Although there are fewer reported studies, the psychoneurologicaland immunological effects of caregiving are receivingincreased attention. A decrease in measures of cellular immunity,and more days of infection following long-term residentialcaregiving of persons with dementia compared to controls alsohas been demonstrated, with caregivers who reported less socialsupport and more stress having the greatest adverse immunefunction effects 13 months later 87 . Alterations in physiologicalfunction as a result of exposure to stress have been found toincrease the probability of illness 100 .Similarly, psychological stress can increase caregiver vulnerabilityto disease by compromising the integrity of the immunesystem 101 . Kiecolt-Glaser et al. 101 have examined depressionand distress as immunological modifiers. Their research teamhas also documented poorer immune response, in particularchanges in the percentages of helper T-lymphocytes andnatural killer (NK) cells, in caregivers of persons withdementia, while controlling for nutritional intake and illnessrelatedvariables 101 .Caregivers in this study also reported nearly three times asmany stress-related symptoms and higher rates of psychotropicdrug use than controls, especially those who were living with theperson with dementia. Other studies comparing psychotropic druguse in caregiving and non-caregiving samples have also reportedthat caregivers use more psychotropic medications than noncaregivingcontrols 15,87,102 . Reports of somatic medication use