Chronic psychiatric illnesses can impair functioning across emotional, interpersonal and occupational domains, and their effects may extend to family members who provide care.[1,2] The responsibilities involved in supporting a person with a persistent psychiatric disorder can therefore have important consequences for the caregiver's own quality of life. Schizophrenia and bipolar affective disorder are both known to be viciously debilitating disorders. While schizophrenia is a severe brain disorder, running mostly with continuous course and reported pooled lifetime prevalence of 0.40 %, bipolar affective disorder is a disabling, episodic, lifelong mood disorder with a prevalence ranging from 1 to 2%.[3,4] Quality of life (QoL) is a multidimensional construct encompassing an individual's perception of physical, psychological and social well-being. In chronic mental illness, disability and the continuing demands of illness management can influence not only the patient but also the family environment in which care is provided.[5] When schizophrenia or bipolar disorder affects a family member, relatives may assume sustained responsibilities related to supervision, treatment, daily functioning and hospital care. Such responsibilities can create emotional, physical and financial strain and may interfere with the caregiver's usual activities.[6] Previous comparative studies have therefore examined whether caregiver QoL differs according to the psychiatric disorder being managed, with findings that have not been entirely consistent.[7,8,9,10] Jain and Singh[7] reported broadly comparable QoL among caregivers of patients with schizophrenia and bipolar disorder. Kaushik and Bhatia[8] examined spouses of patients with the two disorders and reported greater burden and poorer QoL among female spouses of patients with schizophrenia. Narasipuram and Kasimahanti[9] found greater burden together with poorer psychological and environmental QoL among caregivers of people with schizophrenia than among those caring for people with affective disorders. Zendjidjian et al[10], using the SF-36, similarly found that caregivers of people with affective disorders had poorer QoL than the general population but better QoL than caregivers of people with schizophrenia. Long-term caregiving can become a sustained source of strain and may adversely influence family members' QoL.[11] At the same time, earlier studies have produced differing results when schizophrenia and bipolar disorder caregiver groups are compared.[7,8,9,10] Evidence specifically addressing QoL during the relatively stable treatment phase is also limited. A clearer understanding of QoL across the two diagnostic groups may help identify areas in which caregiver-focused psychosocial support could be targeted. The present study was undertaken to compare QoL among caregivers of patients with schizophrenia and bipolar affective disorder.

The study was done at the Department of Psychiatry, Pt. B.D. Sharma PGIMS, Rohtak, a tertiary care hospital. It had a cross-sectional design and involved 30 caregivers each of patients with schizophrenia and bipolar affective disorder. The sample size was estimated after reviewing the last years’ trend of patients diagnosed with schizophrenia and bipolar affective disorder visiting the Department of Psychiatry, Pt. B.D. Sharma PGIMS, Rohtak. Caregivers of the patients whose treatment had not been significantly changed and were not deteriorated to be admitted during past two years of treatment were included. First registered patients, coming for follow up in the psychiatry OPD with their caregiver, who fulfilled inclusion and exclusion criteria were selected and included considering the sample size and the number of OPD days of unit 1 in one week after obtaining the written consent. Caregivers who were 18 years old or more, living with the patient for more than one year prior to inclusion in the study, looking after patient’s daily needs, supervising the treatment, accompanying the patient to the hospital, liaising with the treating team were chosen for obtaining a written consent. The caregivers suffering from any chronic physical and psychiatric disorder including substance use disorder were excluded. Hospitalized patients were not included in the study as it would have resulted in over-reporting of the burden and also decreased the generalizability of the results to the general population. Tools 1. Proforma for Socio-demographic variables: A specially designed proforma was used to gather socio-demographic information about the patients and their caregivers. 2. WHO-QoL-BREF[12]: WHO-QoL-BREF was used for assessing the quality of life of the caregivers. It is a 26-item instrument, which measures four domains of Quality of Life- physical health, psychological, social and environmental. A total Quality of Life score is obtained by summing up the individual score of each item. High score is associated with better Quality of Life with highest possible score being 100. Statistics WHO-QOL-Bref scores was considered as the primary outcome variable. Study group, bipolar disorder Vs schizophrenia (N=30) was considered as primary explanatory variable. Various socio-demographic parameters were considered as other interested variables. All Quantitative variables were checked for normal distribution by using the normality Q-Q plots. For normally distributed WHO-QOL-Bref score parameters, the mean values were compared between study groups using Independent sample t-test (2 groups). P-value < 0.05 was considered statistically significant. Statistical Package for Social Sciences (SPSS) version 22.0[21] was used for statistical analysis. Ethics Appropriate clearance was obtained from the Institute Ethical Committee for the study.

Table 1: Demographic profile of caregivers of patients with bipolar disorder (N= 30) and schizophrenia (N=30). Demographic parameters Bipolar Disorder (N=30) Schizophrenia (N=30) P value Age group Young age (18 to 29) 7 (23.30%) 4 (13.30%) 0.191 Middle age (30 to 49) 12 (40.00%) 8 (26.70%) Old age (50 to 60) 11 (36.70%) 18 (60.00%) Gender Male 20 (66.70%) 21 (70.00%) 0.781 Female 10 (33.30%) 9 (30.00%) Education Illiterate 8 (26.70%) 7 (23.30%) 0.081 Primary 8 (26.70%) 12 (40.00%) Matriculate 2 (6.70%) 7 (23.30%) Higher secondary 9 (30.00%) 2 (6.70%) Graduate 3 (10.0%) 2 (6.70%) Occupation Employed 13 (43.30%) 18 (60.0%) 0.214 Unemployed 8 (26.70%) 3 (10.0%) Housewife 9 (30.0%) 9 (30.0%) Marital status Single 12 (40.00%) 4 (13.30%) 0.061 Married 16 (53.30%) 24 (80.00%) Widow 2 (6.70%) 2 (6.70%) *P value < 0.05 (statistically significant) Table 2: Proportion of caregivers in patients with bipolar disorder (N= 30) and schizophrenia (N=30). Caregiver Study group Chi square P value Bipolar Disorder (N=30) Schizophrenia (N=30) Parents 9 (30.0%) 14 (46.70%) 2.148 0.542 Spouse 13 (43.3%) 9 (30%) Children 6 (20.0%) 6 (20%) Sibling 2 (6.70%) 1 (3.3%) *P value < 0.05 (statistically significant) Table 3: Comparison of WHO-QOL-Bref scores between care-givers of bipolar disorder (N= 30) and schizophrenia (N=30). Parameter Study group P value Inference Bipolar Disorder (N=30) (Mean ±SD) Schizophrenia (N=30) (Mean ±SD) DOMAIN 1 (Physical health) 14.06 ± 2.38 12.8 ± 2.61 0.056 Insignificant DOMAIN 2 (Psychological) 13.27 ± 1.92 11.87 ± 2.7 0.024* Significant DOMAIN 3 (Social) 11.73 ± 3.27 10.18 ± 2.92 0.057 Insignificant DOMAIN 4 (Environmental) 12.4 ± 2.26 11.22 ± 1.92 0.033* Significant Total score 85.03 ± 12.87 76.57 ± 13.95 0.018* Significant *P value < 0.05 (statistically significant) The socio-demographic details of the caregiver population are shown in Table 1. Majority in the bipolar disorder group (43.3%) were spouses while with schizophrenia patients, most of the caregivers (46.7%) were parents. (Table 2) The mean DOMAIN 2 score of bipolar disorder group was 13.27 ± 1.92 and schizophrenia group was 11.87 ± 2.7, the difference between two groups was statistically significant (P value 0.024). Similarly, the mean DOMAIN 4 score of bipolar disorder group was 12.4 ± 2.26 and schizophrenia group was 11.22 ± 1.92, and the difference between two groups was statistically significant (P value 0.033). The mean total score of bipolar disorder group was 85.03 ± 12.87 and schizophrenia group was 76.57 ± 13.95, the difference between two groups was statistically significant (P value 0.018). (Table 3)

The findings should be considered in the context of the substantial demands that can accompany family caregiving in severe mental illness. Caregivers may devote considerable time and energy to treatment supervision and daily support while also managing changes in family roles, social activities and expectations about the illness.[13,14] These demands can influence caregiver well-being and may interact with the course of the patient's illness. Changes in access to treatment and mental-health services also make examination of caregiver experiences relevant in contemporary clinical settings. The two groups were broadly comparable on the socio-demographic characteristics examined. Spouses constituted the largest caregiver category in the bipolar disorder group (43.3%), whereas parents were most frequently represented in the schizophrenia group (46.7%); this difference was not statistically significant. The distributions of age, sex, education, occupation and marital status also did not differ significantly. Thus, major imbalances in the measured socio-demographic variables are unlikely to account for the observed QoL difference. Similar caregiver characteristics have been described in previous comparative work.[15] The present findings are consistent with literature showing that caregiving for people with severe and chronic psychiatric illness can be associated with reduced QoL and substantial burden.[16–18] Earlier work has also suggested that the burden may be particularly pronounced among families caring for people with schizophrenia.[19] In this study, caregivers of patients with schizophrenia had lower overall QoL than caregivers of patients with bipolar disorder. This direction is consistent with Zendjidjian et al.[10], who reported better QoL among caregivers of people with affective disorders than among those caring for people with schizophrenia. Angermeyer et al.[20] also described impairment in caregiver QoL, particularly in psychological well-being and social relationships. In our study, group differences were observed across all four domains, but statistical significance was confined to the psychological and environmental domains. Narasipuram and Kasimahanti[9] similarly identified poorer psychological and environmental QoL among caregivers of people with schizophrenia. Foldemo et al.[17] reported an association between QoL and burden among parents of outpatients with schizophrenia. Nevertheless, previous findings have not been uniform; Jain and Singh[7] reported relatively similar QoL between caregiver groups. Differences in sample characteristics, illness phase, caregiver relationships and measurement methods may contribute to these varying results. The current study has certain limitations being hospital-based, and employing convenience sampling, hence the findings are not generalizable. The cross-sectional design of the study provides limited information about the dynamic influence of various social as well as clinical factors on QoL.

Persistent experience of poor quality of life poses risk of overt as well as substantial sub-syndromal psychiatric morbidity among the caregivers of patients with chronic psychiatric morbidities. Mental health professionals need to be sensitive towards various issues of the caregiving and must evaluate as well as provide appropriate interventions for improving their quality of life. Support programme should be planned to help the caregivers, acknowledging the uniqueness of each situation.

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