Comparison of Caregivers of Schizophrenia and Chronic Renal Failure Patients in Terms of Family Burden , Social Support and Psychological Well-Being

Objective: Schizophrenia is a lifelong chronic psychiatric disorder with a relatively early onset. Renal failure, a chronic physical disorder has also negative effects on the families and causes a serious burden in a similar manner. It is aimed in this study to investigate to what extent the burden, social support and psychological wellbeing among the caregivers of schizophrenic patients compare to those of the caregivers of chronic renal failure patients. Methods: Relatives of patients with schizophrenia and chronic renal failure were included in the study. Each group consisted of 30 volunteers. The volunteers completed demographical information questionnaire, Burden Interview Scale (BIS), Multidimensional Scale of Perceived Social Support (MSPSS) and General Health Questionnaire (GSA). Results: A dominance of female caregivers was found in the study. There was no significant difference between the two groups in terms of burden. Among the caregivers of chronic renal failure was a positive correlation both between age and burden and education and social support respectively. It was found out that relatives of chronic renal failure got less social support and reported a poorer psychological wellbeing when compared to the relatives of schizophrenic patients. A negative correlation was found between social support and burden in both of the study groups. Conclusion: The results of this study underline the importance of social support in alleviating the burden of the caregivers of chronic patients. The monitarisation of the psychological states of caregivers of both the schizophrenic and renal failure patients has to be taken into consideration.


Introduction
Schizophrenia is a chronic psychiatric disorder that usually begins in the early stages of life and continues throughout life.Schizophrenia is a disease that requires lifelong medication and causes significant disability.It adversely affects the family as much as the patient and brings heavy burdens to the family from different angles.
In the acute stages of schizophrenia, the patient's unintelligible symptoms and unpredictable behaviors such as hallucinations and delusions lead to feelings such as fear, helplessness and anger in their family members.It is stated that such feelings are more intense especially at the first episodes and especially when the patients are younger [1].The onset of a serious mental illness in the family leads to feelings similar to emotional reactions to death [2].
The burden is defined as the negative effects that the caregiver feels as a result of dealing with various problems of the patient with a chronic disease [3].In a study conducted with 709 schizophrenia and 646 chronic disease patient relatives; relatives of patients with schizophrenia and neurological diseases were found to have a higher burden than those with renal, diabetic, cardiac and bronchopulmonary diseases [4].Family members sometimes try to fulfill the responsibilities of patients by sacrificing their own needs.The patient and the family's social relationships are weakened due to anhedonia and asociality.Families sometimes restrict their relationships due to their inability to leave the patient alone and their feelings of shame [5] [6].Most patients with schizophrenia live with their parents.In many cultures, families have roles in providing care for patients with schizophrenia.Families often do not know how to cope with disease symptoms [7].
The burden of the caregiver is increased due to the long duration of the disease and the frequency of hospitalization.Assuming the task of providing long-term care may consume the relative of the patient and reduce the coping capacity [8].The social network in which individuals live has a critical role in reducing the harmful effects of stress [9] [10].In particular, it was observed that the patients were less hospitalized and more functional if they had broad social communication and emotional supporters of caregivers of psychotic patients [11] [12].Chronic renal failure leads to severe psychological, social and economic consequences in the individual, family and community triangle [13].In the early 1960s, chronic renal failure was considered to be an absolute deadly disease.As a result of the progression and spread of dialysis applications in the following years, life expectancy of CRF patients has been prolonged [14].It has been found that families have lost their functionality over time due to concerns about death and have become a viewer in the house over time.The wives of the patients and their relatives may have to change their roles and turn into nurses of patients in their lives [15].Social, emotional and economic difficulties caused by a chronic disease and regular dialysis treatment make it difficult to adapt the patient and his/her family.As a result, the life of the patient and his family is adversely affected [16].In dialysis patients, one in the family acts as a dialysis partner and deals with all problems related to dialysis.In this case, the person most affected by the dialysis in the family is the person who is the dialysis partner.Caregivers were found to be adversely affected in terms of mental health and quality of life [14].
The burden of caregiver is also foreseen for the relatives of people with chronic physical illness.Problems negatively affect the course of the life of the patient and his/her family when the sickness shows a chronic course, whether physical or psychological.However, the degree of similarity or difference between the burden of a chronic mental illness and the burden of a chronic physical illness on the lives of people living together has not been adequately investigated.
Based on all these findings, we investigated the differences in caregiver burden, social support and mental health among relatives of patients with schizophrenia and relatives of patients with chronic renal failure.

Method
The study included caregivers of patients with schizophrenia and the caregivers of chronic renal failure patients who received hemodialysis treatment 3 times a week due to chronic renal failure.Family members who agreed to participate were included in the study.30 volunteers were included in both groups.Patient relatives were informed about the study and their consent was obtained.The absence of literacy, having a history of neurological disease, having comorbid psychiatric illness and having a history of mental retardation were defined as exclusion criteria.The sociodemographic data form, Burden Interview Scale (BIS), Multidimensional Scale of Perceived Social Support (MSPSS) and General Health Questionnaire (GSA) were used in the study.
Statistical analysis: The data were analyzed using SPSS 20 for Windows.
Student t test was used for paired comparisons and Pearson moments correlation was used for correlations.The significance level for all values was accepted as p < 0.05.

Results
Of the caregivers included in the study, 44 (73.3%) were female and 16 (26.7%)were male.Both schizophrenia and chronic renal failure patients had a higher number of female caregivers in their groups.23 (76.7%) of the caregivers of schizophrenia patients and 21 (70%) of the caregivers of chronic renal failure patients were women.The youngest of the relatives of schizophrenia patients was 19 and the oldest was 70 years old.The youngest of the relatives of CRF patients was 16 and the oldest was 71 years old.The mean age of the relatives of patients with schizophrenia was 50.1 ± 11.7 and the mean age of relatives of patients with chronic renal failure was 45.6 ± 15.8.There was no significant differ-ence in age between the 2 groups (p = 0.21).In both groups; The mean age of males was significantly higher than the mean age of females (P = 0.01).Regarding education, it was found that the relatives of schizophrenia patients had a mean of 10.0 years, and the relatives of patients with chronic renal failure received 8.4 years of education.There was no difference between the 2 groups in terms of education (Table 1).
According to the Pearson Correlation Test results performed to compare the age and burden of the relatives of schizophrenia patients; The correlation was not statistically significant (p = 0.90).According to the Pearson Correlation Test results performed to compare the age and burden of the relatives of CRF patients; The correlation was statistically significant (p = 0.01).
As a result of comparison of age and GHQ scores with the Pearson Correlation test in schizophrenia patient relatives group; −0.36 negative correlation was detected.This result was statistically significant (p = 0.04).
According to the results of the family burden interview; The mean score of the relatives of patients with schizophrenia was 37.1 ± 14.8 and the mean score of the relatives of patients with chronic renal failure was 30.9 ± 16.7.Comparing the results of relatives of patients with schizophrenia and relatives of patients with chronic renal failure, it was seen that the two groups were not different in terms of family burden.
When the total MSPSS scores of relatives of schizophrenia patients and relatives of CRF patients were compared, it was found that the two groups were not different in terms of social support.In the MSPSS family subscale; The mean score of the relatives of schizophrenia patients was 24.5 ± 3.3 and the mean score of relatives of CRF patients were 20.8 ± 5.6.A statistically significant difference was found between the two groups in the MSPSS family subscale (P = 0.04).
The mean GHQ score of the relatives of schizophrenia patients was 2.5 ± 2. and the mean GHQ score of the patients with CRF was 4.1 ± 2.7.The relatives of CRF patients had higher scores in the GHQ than the relatives of patients with schizophrenia.There was a statistically significant difference (p = 0.02) between the mean scores of 2 groups (Table 2).

Discussion
Most people with chronic illnesses, whether physical or mental, need help from their relatives in terms of emotional, economic support and other needs.While families often provide this support to their relatives, they feel the burden of care.
People who support the patient in the family and spend most of their time together with them experience different problems in all aspects of life [17].In our study, it was found that the majority of caregivers in the group of relatives of schizophrenia patients and in the group of relatives of patients with chronic renal failure were women.76.7% of the relatives of patients with schizophrenia and 70% of the relatives of patients with chronic renal failure were women.The fact that the majority of caregivers in both groups were women was thought to reflect a cultural effect.
One of the findings in the study was that the average age of males in both groups was statistically significantly higher than the average age of females.As a result, the number of caregiving men compared to women is low and older, and if there is no female caregiver in the family, it supports the idea that caregiving is done by men at that time.
Many studies have found that the caregivers for patients with schizophrenia are mostly mothers.In most cases, mothers assume almost all responsibility and care for schizophrenia patients [18].In our study, it is noteworthy that the caregivers of schizophrenic patients are mostly mothers, while caregivers are predominantly spouses of CRF patients.This difference can be attributed to the inability of schizophrenia patients to get married or to divorce due to illness.According to our study, while the burden did not increase with age at the relatives of schizophrenia patients, it was found that there was an increase in the relatives of CRF patients.This condition is thought to be due to the need of more intensive treatment of chronic renal failure compared to schizophrenia.
Social networks are the most important factor in adapting to deal with problematic situations and it is known that social networks increase as education level increases [9].In our study, it was determined that the social support of the relatives of CRF patients increased as their education duration increased.There was no significant relationship between the level of education and social support in the relatives of schizophrenia patients.This difference may be due to the fact that CRF is more easily accepted by society as a chronic physical disease.On the contrary, it is thought that schizophrenia may be more difficult to be accepted by society, which brings stigma related problems together with the patient and his family.
According to our findings, there was no significant difference in the burden between relatives of patients with schizophrenia and relatives of patients with chronic renal failure.Burden interview scores of the relatives of schizophrenia patients were higher than those of the relatives of CRF patients.In our study; It was determined that the relatives of patients with chronic renal failure had less support than their families according to the relatives of schizophrenia patients.This result was thought to be due to the need for more continuous and intensive care of CRF patients compared to schizophrenia patients.
According to GHQ results; It is seen that there is a higher psychological distress in the relatives of patients with CRF than in relatives of schizophrenia patients.This result shows that the relatives of CRF patients are in worse condition in terms of mental well-being.This difference between the two groups can be explained by having more physical diseases and less family support, in the group of CRF patients relatives.
According to the results of our study, it was observed that as the social support increased in both groups, the burden of patient caregivers decreased significantly.This result demonstrates the importance of social support in reducing the burden of caregivers.We think that social activities should be increased in order to reduce the effects of disease on relatives of CRF and schizophrenia patients.We believe that socialization will have important functionality in reducing the burden of caregivers.
In the light of the data obtained from our study; It is important to note that the participation of families in this process is important in order for the treatment to be successful, whether it is psychiatric as schizophrenia or chronic physical disease such as CRF.The contribution and participation of the families in the treatment affects the results in a good way.However, in order for this cooperation to be successful, the mental and physical conditions of the family caregivers should be good.It should not be overlooked that, if the target is only patient-focused, there will be no success above a certain level, and that the mental status of families, especially primary caregivers, should be carefully monitored.It is thought that as the social support of caregivers increases, their burden will decrease and they will feel better.It is hoped that as the positive approaches and efforts of caregivers to their patients increase, the success of the treatments will be better.
Identifying the socio-economic and psychosocial problems of the family, which is an important support system for the treatment of physical and mental diseases, and producing solutions will be a guide for long-term treatment planning of chronic diseases.

Table 2 .
Comparison of demographic and psychological variables of 2 groups.