CAREGIVER BURDEN IN BPAD: A SYSTEMATIC REVIEW

Publishing article: Asian journal of psychiatry

AUTHOR: not included
Title: Caregiver burden in BPAD: a systematic review
ABSTRACT
The aim of the present review was to acquire knowledge on the perceived level of burden among caregivers of persons
with BPAD, in order to gain understanding about the intensity of need for action. In order to provide a critical review
about caregivers burden in patients with BPAD, we performed a detailed PubMed, ProQeust, EBSCO HOST,
PsyINFO, MEDLINE, SAGE Journals and Springer search to identify all papers and book chapters in English
published during the period between 2001 and 2016. We reviewed 19 studies including 3 Indian studies. The illness of
the patient was noted as the main cause of caregiver burden in 47% of reviewed article. The illness of the patient was
noted as the main cause of caregiver burden in 47% of reviewed article. As per 37% of the articles reviewed, the main
cause for caregiver burden was impact of patients illness on caregivers work, social relationship, and leisure time.
Role conflict was another cause in 32% of article reviewed. 26% of the studies revealed that poor financial
background as a cause for caregiver burden. There is a need to better understand caregivers view and personal
perceptions of the stress and demands arising from caring for someone with BPAD in order to develop practical
appropriate interventions and to improve the training of caregivers.
KEY WORDS: Bipolar Disorder. Caregivers, Burden, Prevention

1. INTRODUCTION

Bipolar disorder (BPAD) is a complex chronic mood disorder characterized by episodes of an exalted mood
known as mania alternating with episodes of depression. Psychosocial and familial factors have been
implicated in the occurrence and course of BPAD. Recently, evidence-based research has shown that
psychosocial interventions positively affect treatment outcome in BPAD patients.1

The prevalence rates of bipolar I (one episode of mania), and bipolar II (at least one episode of mania and at
least one episode of depression) were 0.6 per cent, and 0.4 per cent, respectively, with an overall prevalence
of 2.4 per cent. The United States had the highest prevalence rate of bipolar spectrum (4.4 per cent), while
India had the lowest rate (0.1 per cent). More than half of those with bipolar disorder in adulthood note that
their illness began in their adolescent years.2

Due to the episodic nature and course of BPAD (with a natural, mixed, or rapid cycling course), the burden
experienced by the caregivers of BPAD patients differs from that of the caregivers of patients with other
psychiatric disorders. In contrast to other chronic disorders, such as schizophrenia, dementia, and unipolar
depression, the coping patterns of the caregivers of BPAD patients have not been thoroughly examined. The
relatives of BPAD patient experience an increase in the expenditure of time and money, as well as stress,
distress, and sorrow.1

In the context of caregiving, it is important to differentiate the concept of caregiver burden from the concept
of family burden. The term caregiving tends to focus on providing actual assistance in response to the
illness and this experience may have both positive and negative elements within the experience. Family
burden on the other hand, tends to be considered as the emotional experience (typically negative) associated
with a relatives illness, but this individual may or may not be involved in the provision of practical
assistance3,4

Caregiver burden has been adopted to identify the objective and subjective difficulties experienced by
relatives of people with long-term mental disorders. Objective burden relates to the practical problems
experienced by relatives such as the disruption of family relationships, constraints in social, leisure and work
activities, financial difficulties, and negative impact on their own physical health. Subjective burden
describes the psychological reactions in which relatives experience, e.g. a feeling of loss, sadness, anxiety
and embarrassment in social situations, the stress of coping with disturbing behaviours, and the frustration
caused by changing relationships. Grief may also be involved. This may be grief for the loss of the persons
former personality, achievements and contributions, as well as the loss of family lifestyle. This grief can lead
to unconscious hostility and anger.5

1.1 Background and need for the review

In 2004, the World Health Organization ranked bipolar affective disorders (BPAD) collectively as the 12 th
most common moderately to severely disabling condition in the world for any age group, with a lifetime
prevalence of 4 per-cent in the United States. Bipolar disorders have no preference for race, sex, or ethnicity.
Although they can occur at any age, bipolar disorders are most common in persons younger than 25 years.
The mean age at symptom onset is 18 years in bipolar I disorder and 22 years in bipolar II disorders6

Many caregivers are significantly distressed by the way the patient related to them when unwell. Partners
and parents particularly found this stress major. In addition, most of the caregivers experienced significant
disruption in social activities and leisure pursuits when the patient was unwell, especially partner caregivers.
It seems clear the caregivers cope better with illness related symptoms than actions related to the patient
personality.7

In one study, caring for a family member is not perceived to be a burden, and caregivers reported limitations
in their social networks and social activities. They reported higher levels of unemployment than would be
expected for the general population and were over-represented in lower income groups. Family carers are at
high risk of social and economic disadvantage and at high risk of mental health challenges. Highly stressed
persons may not be able to benefit from attempted social support of others as much as moderately stressed
persons.7

Caregiver burden also predicted patients medication non-adherence 7 months later and recurrence or
continuation of a major affective episode within the 15 months following the initial assessment. Other
studies have found that caregiver burden is associated with long-term financial difficulties among
caregivers, along with marital strain, restrictions in social and leisure activities, and problems with health
and mental health.8

Lack of attention to the views of caregivers, the nature of the relationship between caregiver and patient,
social circumstances and culturally situated health beliefs could be a risk in terms of impact upon both
treatment interventions and the burden of care experienced by informal caregivers. A need to understand
caregivers views and perceptions of the stress and demand arising from caring for someone with BPAD is
emerging because developing practical, appropriate and acceptable interventions and improving the training
of professionals working with persons/patients with BPAD and their caregivers can make patient outcomes
better and reduce caregiver distress.9 Hence, the reviewer has done a systematic review of studies related to
caregiver burden in BPAD from the year 2001 onwards.

Aim of this review was to acquire knowledge on the perceived level of burden among caregivers of persons
with BPAD, in order to gain understanding about the intensity of need for action.

2. METHOD
After identifying the need for the particular review, inclusion and exclusion criteria for the papers to be
reviewed were prepared, according to which the review was carried out, using different search strategies by
adopting the interfaces and databases. The collected papers were checked for clarity and then used for the
review. Qualitative, quantitative and mixed research studies were included.
 2.1 Eligibility Criteria

The review was done to identify the articles that explicitly described the nature of caregiver burden in BPAD
and contributing factors. The author included the literature related to caregiver burden in BPAD published
from the year 2001 to include recent studies. Studies with insufficient data such as inadequate information
on research methodology, studies related to caregiver burden in mental illness other than BPAD and
systematic reviews were excluded.

2.2 Literature search strategies and data sources:

The steps involved in the literature search are as follows:

Discard irrelevant or
inappropriate references

Device
search Search
Abstract
strategy for, Screen for Read Critique Analyse
and(select identify relevance, source and and
encodedata & and material evaluate integrate
bases, retrieve appropriat
identify primary eness
key source
words

Prepare/ Identify new

synthesis Document
critical search decisions
summary

Figure 1 Flow chart showing the steps included in the literature search

(Source; Polit & Beck, Textbook of Nursing Research, 2011)

The literature was obtained from the databases such as ProQeust, PubMed, EBSCO HOST, PsyINFO,
MEDLINE, SAGE journals and Springer using the following keywords and Boolean terms. Web based
resources were identified by internet searches using Google and Google scholar advanced search.

2.3 Data extraction and quality assessment

The extracted data were assessed based on eligibility criteria. The quantitative studies were evaluated on the
basis of relevance, appropriateness, and methodology. Those studies which are not meeting the criteria were
excluded as specified by the quality assessment tool for quantitative studies (Appendix No: 1) Qualitative
studies were assessed for quality by using the Critical Appraisal Skills Programme (CASP) qualitative
research checklist. Those studies which were not fitting into the quality checklist were excluded.
 Total number of articles
obtained, n=70

Full text articles, n= 60 (Full Abstracts, n=10

text studies, n= 57, Systematic
review n=3)

Excluded (n=10)
Excluded full text (n=41)

Included n=0
Included n=19

Number of articles reviewed,

Figure 2 Flow diagram showing the selection of review article

2.4 Data analysis

The steps in the data analysis are:
Step 1: Preliminary classification and tabulation of studies

The relevant articles were studied and the data were extracted. The data so obtained were tabulated and
classified as: Author, Year of publication, Location, (country), Approach/design , Instruments , Sample size,
and Major findings
Step 2: Identifying the findings of the study

The socio demographic characteristics of sample and major findings spotted in each study were identified.
The interventions recommended or suggested in these studies were also noted.

Step 3: Categorizing the studies based on socio demographic characteristics of the sample

The major socio demographic factors mentioned in the reviewed article were enlisted, counting was done
and the percentage distribution was calculated.
Step 4: Categorizing the studies based on causes/ factors of caregiver burden and indicators of
caregiver burden in BPAD

The major causes/factors of caregiver burden and indicators of caregiver burden were enlisted, counting was
done and percentage distribution was calculated.
Step 5: Categorizing the studies based on the interventions recommended for caregiver burden in
BPAD.
The major themes of interventions for caregiver burden in BPAD recommended or suggested in these studies
were identified, and the studies were categorized accordingly to determine the percentage distribution.
3. RESULT
3.1 Baseline data
All the studies included in the review were published in the time period of 2001-2015, out of which there
were 15 quantitative studies, 3 qualitative studies and 1 study with mixed research methodology. The articles
included in the review were conducted in different parts of the world namely USA (6), India(3), Germany
(3), Turkey(2), Spain (1), Netherland(1), Poland(1), Ethiopia (1) and Brazil(1)
3.2 Major findings
Participants were recruited from a range of settings, including hospitals and clinics and community based
outreach programmes. Subjects of the studies included caregivers of patients with BPAD. The sample size of
the quantitative studies varied from 34 to 904 with a mean sample size of 264. The sample size in qualitative
studies varied from 15 to 32 with a mean sample size of 26. The mixed method study had a sample size of
30. The mean sample size of the entire studies was 200.
All studies focused on caregiver burden in BPAD, and some studies compared caregiver burden in BPAD
with caregiver burden in other mental and physical disorders. But all the studies recommended interventions
to reduce the caregiver burden in BPAD.
The findings were mainly based on the socio demographic characteristics of the sample, causes/factors of
caregiver burden, indicators of caregiver burden and interventions as recommendations for caregiver burden
in BPAD.
3.2.1 Socio demographic variables associated with caregiver burden among patients with BPAD
The socio demographic variables which showed an association in the reviewed articles were identified.
Counting was done and the frequency and percentage were calculated. Majority of the studies cited high
level of caregiver burden associated female gender followed by number of admission, and marital status.
The age, number of admissions, duration of illness also had significant association with severity of caregiver
burden in few studies.
Table 2 Socio demographic variables associated with caregiver burden among patients with BPAD
n=19

Sl no. Socio demographic variables associated with caregiver No. of Percentage

burden among patients with BPAD studies
1 No of admissions >2 8 42%
2 Gender Female 7 37%
Male 2 10%
3 Marital status Married 6 32%
4 Length of illness >3 years 5 26%
5 Age 20-30 years 2 10%
30-40 years 5 26%
41-50 years 3 16%
6 Duration of stay with >1year 3 16%
patient

3.2.2 Causes of caregiver burden/ factors associated with caregiver burden in BPAD
Caregiver burden in BPAD is due to multiple reasons which were identified from the reviewed articles.
Table 3 Causes of caregiver burden/ factors associated with caregiver burden in BPAD
n= 19

Sl Causes of caregiver burden/ factors associated with caregiver No of studies Percentage

no burden in BPAD
1 Illness of the patient 9 47%
2 Impact of patients illness on caregivers work, social 7 37%
relationship, and leisure time
3 Role conflict 6 32%
4 Poor financial background 5 26%
5 Spouse related issues 4 21%
6 Lack of social support 4 21%
7 Social stigma 3 15%
8 Medication non-adherence 2 10%
9 Suicidal attempts by the patient 2 10%
10 Substance abuse by the patient in remission 1 5%
11 Mental illness in other family member 1 5%

The illness of the patient was noted as the main cause of caregiver burden in 47% of reviewed article. As per
37% of the articles reviewed, the main cause for caregiver burden was impact of patients illness on
caregivers work, social relationship, and leisure time. Role conflict was another cause in 32% of article
reviewed. 26% of the studies revealed that poor financial background as a cause for caregiver burden. Lack
of social support, spouse related issues, medication adherence were also identified in many studies followed
by suicidal attempt by the patient, and lack of social support. The other causes of caregiver burden such as
substance abuse, and mental illness in other family member were also noted in few studies.
3.2.2 Indicators of caregiver burden
The burden in caregivers of patient with BPAD can be easily identified with certain indicators
Table 4 Indicators of caregiver burden
n=19

Sl no Indicators of caregiver burden No of studies Percentage

1 Physical health issues 8 42%
2 Financial issues 5 26%
3 Depression 4 21%
4 Anxiety 2 10%
5 Emotional over involvement 1 5%
6 Decreased social interaction 1 5%
7 Suicidal ideation 1 5%
8 Marital discord 1 5%
9 Substance abuse in caregivers 1 5%
10 Lack of self-care 1 5%
11 Increased health service use 1 5%
12 Guilty feelings 1 5%
13 Loss of job 1 5%
14 Searching for religious meaning 1 5%
15 Fear of future 1 5%
The burden can be easily identified with certain specific indicators. Most of the article reviewed (42%)
identified physical health issues as the most burdensome aspect of caregiving. Most of the caregivers
suffered from physical health problems associated with caregiving in BPAD. Depression was a mental health
issue faced by the caregivers of BPAD noted in 21% of the articles reviewed. 10% articles reviewed
mentioned anxiety as another major mental health issue for the caregivers of BPAD. The other indicators of
caregiver burden such as emotional over involvement, decreased social interaction, marital discord, suicidal
thoughts were also identified in few studies followed by substance abuse, lack of self-care and increased use
of health service.
3.2.3 Interventions recommended for caregiver burden in BPAD

Table 5 Interventions recommended for caregiver burden in BPAD

n=19

Sl no Interventions recommended for No of studies Percentage

caregiver burden in BPAD
1 Psycho educational intervention
2 Family intervention
3 Coping skill training
4 Mental illness prevention program
5 Health policy and priority setting
6 Spousal support
7 Unspecified intervention
4 21%
2 11%
2 11%
1 5%
1 5%
1 5%
8 42%

The majority of the studies (42%) reviewed did not mention what interventions should be given for
caregivers with high level of burden. But 21% articles reviewed very specifically recommended psycho
educational intervention for caregiver burden in BPAD. Family intervention was recommended in many
studies for caregiver burden. Conducting mental illness prevention programs were considered important in
few studies. Few studies mentioned that support to the spouse should be given to reduce the caregiver
burden. A health policy and priority setting was also suggested in few studies.
4. DISCUSSION

4.1 Discussion about major findings

The caregivers role is difficult, frequently distressing and affects health including quality of life. A high
burden level on relatives of persons/patients with BPAD has been reported and recent studies have shown
that caregivers burden may influence the clinical outcome of BPAD.10,11

The burden of caring for a psychiatrically ill family member has been classified into two categories, the
objective and the subjective burden. The first category is what happens to family life that can be
observed and verified, including separation and divorce in marriages, reduced social and leisure activities
due to fears of stigma and financial difficulties. The second category involves personal feelings such as
burden who often feels distressed, upset and unhappy.32

Perlick et al. (2004) argued that caregivers with a higher level of distress can behave differently towards the
patient and this could affect the clinical outcome. Reducing burdensome aspects might help to abolish the
negative effects on both the caregivers and patient outcome. According to the literature, a prolonged illness
and high levels of impairment among patients, caregiver illness beliefs and coping style influence the family
burden perceived by relatives of persons with BPAD. The illness often impacts on the partners life. Most
partners said that the illness made their relationship difficult and, as a result, separations because of illness-
related difficulties were common.11
Most of the articles reviewed here mentioned that the main causes for caregiver burden are patient illness,
impact of patients illness in caregiver life, role conflict and financial issues. Regarding burdensome
aspects, Perlick et al. (2004) identified that the most frequently distressing behaviours for caregivers were
hyperactivity, irritability and withdrawal.11
Some disruptions include changes to household, social and leisure activities, employment and finances.
Caregivers of persons/patients with BPAD who had experienced a relapse during the previous 2 years
experienced a higher level of burden, especially subjective burden, according to the number of previous
episodes. So, the level of burden may be sensitive to recent crises, as reported by Perlick et al (2004).11

It is very clear that caregivers relationships with friends, family and acquaintances were often affected,
resulting in the loss of friendships, tensions with neighbours and the experience of being stigmatised,
especially with respect to police involvement with the patients illness. The majority of caregivers needed
time off work and a third of caregivers had experienced a salary reduction since the onset of the illness. As a
result, the caregiving role compromises other social roles occupied by the caregiver, becoming part of the
heavy social cost of bipolar affective disorder. Severity of illness (defined as percentage of time unwell) was
associated with greater caregiver burden.7

The economic impact of caregiving was expressed by time off from paid work because of caring obligations,
the impossibility of accepting a full-time job and offering flexibility that employers might normally require
or, in other words, to use their potential in economic/career terms, etc. A study in the United States showed
that direct economic consequences were represented by the significant financial contributions that family
members, especially parents and siblings, often make in order to support their relatives with BPAD.30

Chessick et al. (2009) had two major findings. Firstly, suicidal ideation increase in BPAD patients from
baseline to 6 and 12 more reported worse general health to caregivers than a stable or decrease in baseline
suicidal ideation, probably because caregivers could overextend themselves in the hope of saving the
patient by taking on more responsibility for the patient than is sustainable for long periods of time.
Secondly, more suicidal ideation and more depressed mood at baseline and follow-up points have been
correlated with more depressed mood at each time interval.16

Finally, subjective burden is also influenced by the sense of responsibility for drug intake. As a result,
avoiding relapses or increasing the time to relapse, improving inter-episode functioning, promoting the
autonomy of the patient and reducing the caregivers responsibility level for the patients treatment should
be crucial goals of psychosocial treatment of BPAD.14

According to the tripartition of caregivers defined by Platt (1985), the effective caregivers have reported no
diseases, a low level of stress and adaptive coping; the burdened caregivers have shown a high level of stress
linked to the subjects behavior and less adaptive coping; the stigmatized caregivers were stressed due to
perceived stigma, effective coping and were healthy. The level of stress and health among caregivers are
strictly linked, whereas those with a higher degree of caregiving strain have poor physical and mental
health.29

Most people who view themselves as informal caregivers have experienced an important transition in which
existing spousal, family or friendship relationships were superimposed on the relationship of carer-cared
for. These changes are related to specific symptoms, key illness related events and the stage of the disorder,
but very little is known about the factors mediating these changes.31
Lack of attention to the views of caregivers, the nature of the relationship between caregiver and patient,
social circumstances and culturally situated health beliefs could be a risk in terms of impact upon both
treatment interventions and the burden of care experienced by informal caregivers.31

It was found that parents of persons with BPAD may benefit from a variety of interventions. Generally, the
interventions to reduce caregivers burden could be grouped under simple interventions at clinicians level
(e.g., enquiring about burden, psycho educational and support interventions) and the more complex
interventions such as family interventions. It has been suggested that identifying and modifying burdensome
aspects may help to reduce the level of burden and their negative effects on the caregivers thereby improving
patients outcome.14

A need to understand caregivers views and perceptions of the stresses and demands arising from caring for
someone with BPAD is emerging because developing practical, appropriate and acceptable interventions and
improving the training of professionals working with persons with BPAD and their caregivers can make
patient outcomes better and reduce caregiver distress.31

4.2 Limitations

This review has number of limitations. The review was done with 19 papers due to time constraints
and single reviewer and quality assessment method for the reviewed article was limited to CASP
checklist. Another limitation is external suggestions or reviewer triangulation were not adopted
during data analysis. Also, more literature might be available other than that located with our search
strategy. Furthermore, another criticism must be reported. Review was specified to caregiver burden
in person with BPAD only so the findings cannot be generalized to other psychiatric disorders. We
stress the need of further research in this field.

5. CONCLUSION
Bipolar disorder is extremely burdensome for caregivers. The ease with which patients bipolar illness
induces discomfort in other people makes it impossible for caregivers to remain unaffected. The present
knowledge on caregiver burden in times of bipolar disorder is not enough to plan an effective interventional
package. This overview highlighted the need to better understand caregivers views and personal perceptions
of the stresses and demands arising from caring for someone with BPAD in order to develop practically
appropriate interventions and to improve the training of caregivers. It is also not yet clear how nurses can
support those who care for their near and dear ones prior to the moment when the symptoms of bipolar
disorder become too burdensome

6. REFERENCES
1. Erten E, Alpman N, zdemir A, Fstkc N. The impact of disease course and type of episodes in
bipolar disorder on caregiver burden, Article in Turkish journal, 2014, Vol 24 (2) :114-23
2. Merikangas KR1, Jin R, He JP, Kessler RC, Lee S, Sampson NA, Viana MC, Andrade LH, Hu C,
Karam EG, Ladea M, Medina-Mora ME, Ono Y, Posada-Villa J, Sagar R, Wells JE, Zarkov
Z.Prevalence and correlates of bipolar spectrum disorder in the World Mental Health Survey
Initiative. Archives of General Psychiatry. March 2011. 68(3):241-251.
3. Sales E, Family burden and quality of life. Quality Life Res journal. 2003. 12( 1):33-41.
4. Poulin MJ, Brown SL, Ubel PA, Smith DM, Jankovic A, Langa KM. Does a helping hand mean a
heavy heart? Helping behavior and well-being among spouse caregivers, Psychology of Aging
journal. 2010. Vol. 25:108-117.
5. Ostman, M. and L. Hansson. Appraisal of caregiving. burden and psychological distress in relatives
of psychiatric inpatients. European Psychiatry journal. 2004. Vol 19 (7): 402-407.
6. Merikangas KR, Akiskal HS, Angst J, et al. Lifetime and 12-month prevalence of bipolar spectrum
disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry journal. 2007. Vol
64(5):543552.
7. Dore G, Romans SE. Impact of bipolar affective disorder on family and partners. Affect Disorder
journal. 2001. Vol 67:147158.
8. Perlick DA, Rosenheck RA, Miklowitz DJ, Chessick C, Wolff N, Kaczynski R, Ostacher M, Patel J,
Desai R. Prevalence and correlates of burden among caregivers of patients with bipolar disorder
enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder. Bipolar Disorders.
2007 May 1;9(3):262-73.
9. Platt S. Measuring the burden of psychiatric illness on the family: an evaluation of some rating scales
Psychology Med journal. 1985;15:383393.
10. Chakrabarti S1, Gill S. Coping and its correlates among caregivers of patients with bipolar disorder:
a preliminary study. BipolarDisord. 2002. Feb;4(1):50-60.
11. Perlick DA, Rosenheck RA, Clarkin JF, Maciejewski PK, Sirey J, Struening E, Link BG. Impact of
family burden and affective response on clinical outcome among patients with bipolar disorder.
Psychiatr Serv. 2004. Sep;55(9):1029-35.
12. Perlick DA1, Hohenstein JM, Clarkin JF, Kaczynski R, Rosenheck RA. Use of mental health and
primary care services by caregivers of patients with bipolar disorder: a preliminary study.
BipolarDisord. 2005 Apr;7(2):126-35
13. Wolff N, Perlick DA, Kaczynski R, Calabrese J, Nierenberg A, Miklowitz DJ. Modeling costs and
burden of informal caregiving for persons with bipolar disorder. J Ment Health Policy Econ. 2006
Jun;9(2):99-110
14. Reinares M1, Vieta E, Colom F, Martnez-Arn A, Torrent C, Comes M, Goikolea JM, Benabarre A,
Daban C, Snchez-Moreno J. What really matters to bipolar patients' caregivers: sources of family
burden. J Affect Disord. 2006 Aug;94(1-3):157-63. Epub 2006 Jun 5.
15. Schmid R, Huttel GU, Cording C, Spiessl H. The situation of caregivers of inpatients with bipolar
affective disorders. FortschrNeurolPsychiatr. 2007 Nov;75(11):665-72.
16. Chessick CA, Perlick DA, Miklowitz DJ, Kaczynski R, Allen MH, Morris CD, Marangell LB.
Current suicide ideation and prior suicide attempts of bipolar patients as influences on caregiver
burden. Suicide Life Threat Behav. 2007 Aug;37(4):482-91.
17. Perlick DA, Rosenheck RA, Miklowitz DJ, Chessick C, Wolff N, Kaczynski R, Ostacher M, Patel J,
Desai R. Prevalence and correlates of burden among caregivers of patients with bipolar disorder
enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder. Bipolar Disorders.
2007. May 1;9(3):262-73.
18. Zergaw A1, Hailemariam D, Alem A, Kebede D. A longitudinal comparative analysis of economic
and family caregiver burden due to bipolar disorder. Afr J Psychiatry (Johannesbg). 2008
Aug;11(3):191-8.
19. Ostacher MJ, Nierenberg AA, Iosifescu DV, Eidelman P, Lund HG, Ametrano RM, Kaczynski R,
Calabrese J, Miklowitz DJ, Sachs GS, Perlick DA. Correlates of subjective and objective burden
among caregivers of patients with bipolar disorder. ActaPsychiatr Scand. 2008 Jul;118(1):49-56.
20. Van der Voort TY1, Goossens PJ, van der Bijl. Alone together: A grounded theory study of
experienced burden, coping, and support needs of spouses of persons with a bipolar disorder. Int J
Ment Health Nurs. 2009 Dec;18(6):434-43.
21. Bauer R1, Gottfriedsen GU, Binder H, Dobmeier M, Cording C, Hajak G, Spiessl H. Burden of
caregivers of patients with bipolar affective disorders. Am J Orthopsychiatry. 2011 Jan;81(1):139-48.
22. M. Ak, F. Yavuz, N. Lapsekili, H. Turkcapar. Evaluating the caregivers of bipolar disorder patients
with zarit burden interview. European psychiatry. 2012 . Volume 27(1) ; 1-4
23. Maji KR, Sood M, Sagar R, Khandelwal SK. A follow-up study of family burden in patients with
bipolar affective disorder. Int J Soc Psychiatry. 2012 Mar;58(2):217-23
24. Vasudeva S, Sekhar CK, Rao PG. Caregivers burden of patients with schizophrenia and bipolar
disorder: a sectional study. Indian J Psychol Med. 2013 Oct;35(4):352-7
25. Borowiecka-Karpiuk J, Dudek D, Siwek M, Jaeschke R. Spousal burden in partners of patients with
major depressive disorder and bipolar disorder. Psychiatr Pol. 2014. Jul-Aug;48(4):773-87.
26. Da Silva Gdel G, Jansen K, Barbosa LP, BrancoJda C, Pinheiro RT, Magalhes PV, Kapczinski F, da
Silva RA. Burden and related factors in caregivers of young adults presenting bipolar and unipolar
mood disorder. Int J Soc Psychiatry. 2014 Jun;60(4):396-402.
27. Erten E, Alpman N, zdemir A, Fstkc N. The impact of disease course and type of episodes in
bipolar disorder on caregiver burden. Turk PsikiyatriDerg. 2014 Summer;25(2):114-23.
28. Bauer R, Spiessl H, Helmbrecht MJ. Burden, reward, and coping of adult offspring of patients with
depression and bipolar disorder. Int J Bipolar Disord. 2015 Jan 31;3:2.
29. Platt S. Measuring the burden of psychiatric illness on the family: an evaluation of some rating
scales. Psychol Med. 1985;15:383393.
30. Simon GE. Why we care about the economic and social burden of bipolar disorder. Bipolar Disorder-
WPA Series on Evidence and Experience in Psychiatry. London: John Wiley & Sons; 2002. pp. 474
476.
31. Ogilvie AD, Morant N, Goodwin GM. The burden on informal caregivers of people with bipolar
disorder. Bipolar Disord. 2005;7 Suppl 1:2532.
32. Fadden G, Bebbington P, Kuipers L. The burden of care: the impact of functional psychiatric illness
on the patients family. Br J Psychiatry. 1987;150:285292.