Asian Journal of Psychiatry 54 (2020) 102219

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Coping with caregiving stress among caregivers of patients with T

schizophrenia
Pradyumna Rao, Sandeep Grover*, Subho Chakrabarti
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India

A R T I C LE I N FO A B S T R A C T

Keywords: This study aimed to evaluate the coping strategies, including religious coping, used by the caregivers of patients
Coping with schizophrenia to deal with caregiving stress. Caregivers of 100 patients with schizophrenia, currently in
Schizophrenia clinical remission, were evaluated on Ways of the coping questionnaire, Brief religious coping scale, and General
Caregivers Health Questionnaire (GHQ-12). More often use of adaptive coping mechanisms (such as seeking social support,
accepting responsibility, planful problem solving, and positive reappraisa) was associated with a lower level of
residual symptoms and better functioning of the patient, and lower level of psychological morbidity as per the
GHQ-12 among the caregivers. A higher grade of negative symptoms, general psychopathology, and PANSS total
score was associated with lower use of positive religious coping and higher use of negative religious coping in the
caregivers. More severe psychological morbidity among the caregivers was associated with lower use of positive
religious coping and higher use of negative religious coping.
To conclude, this study depicts that caregivers of patients with schizophrenia use a mixture of adaptive and
maladaptive coping strategies, including religious coping. The use of adaptive coping is associated with better
patient-related outcomes and lower levels of psychological morbidity/distress among caregivers. Whereas, more
frequent use of maladaptive coping is associated with both patients' and caregivers' outcomes.

1. Introduction coping resources) appraisal.

Schizophrenia is an illness that not only places a considerable
burden on the afflicted individuals but also poses a significant challenge
to their caregivers. Those caregivers of patients with schizophrenia who
are unable to cope with the overwhelming caregiving distress, develop
psychological morbidity, and reduced quality of life.
The dominant paradigm which tries to explain the caregiving pro-
cess includes the stress-appraisal-coping (or the stress-coping), which
was put forth by Lazarus and Folkman to explain the process of coping
with stress (Lazarus and Folkman, 1984). This model has been subse-
quently adopted by other researchers to explain caregiving's process
among family members of those with chronic psychiatric disorders
(Scazufca and Kuipers, 1999; Hassan et al., 2011; Kate et al., 2013a;
Hegde et al., 2019). This model assumes that taking care of a person
with mental illness is stressful for the caretaker. The patients' problem-
behaviors, disabilities, and the burden caused by them constitute the
significant stress that caregivers face, and appraisal of these stresses
calls for different coping mechanisms. An estimate is understood as
evaluative judgments of the caregivers and can be primary (i.e., de-
mands of the caregiving situation), or secondary (the adequacy of
Mediators of appraisal and coping strategies include attributes of
the caregiver’s, i.e., demographic and personality characteristics, socio-
cultural factors, and the degree of social support. The eventual out-
come, i.e., distress or well-being of the caregivers, is determined by the
interaction between the stressors, appraisal of the stress, and coping
strategies used. When coping is ineffective in reducing the appraised
stress, this results in physical or psychological distress for the caregiver
(Magliano et al., 1995; Scazufca and Kuipers, 1999; Grover et al.,
2015). When one carefully looks at this model, it becomes evident that
coping is an important determinant that influences the psychological
state of the caregivers. Hence, accordingly, improving adaptive coping
can lead to improved outcomes of the caregivers and possibly that of
patients.
Coping is the process of managing taxing or overwhelming demands
(external or internal) on the person (Lazarus and Folkman, 1984).
Coping mechanisms are classified in many ways, and some of the
popular categories include adaptive versus maladaptive, positive versus
negative coping, and problem-focused coping and emotion-focused
coping. Additionally, it suggested that many persons also use religious
coping to deal with stress. Religious coping is a multidimensional

⁎
Corresponding author.
E-mail address: drsandeepg2002@yahoo.com (S. Grover).

https://doi.org/10.1016/j.ajp.2020.102219
Received 19 April 2020; Received in revised form 27 May 2020; Accepted 9 June 2020
1876-2018/ © 2020 Published by Elsevier B.V.
P. Rao, et al.
concept. It is categorized as positive (spiritual support and collaborative
religious coping, congregational support, benevolent religious re-
framing), and negative (discontent with one's congregation and with
God and negative religious reframing, i.e., seeing the illness as God's
punishment) religious coping. Additionally, a category of mixed im-
plications (religious rituals performed during the crisis, self-directing,
deferring, and pleading religious coping) is also described in the lit-
erature (Pargament, 1997; Pargament et al., 2000). Positive religious
coping (PRC) strategies have been shown to help in dealing with the
stressful life situations. In contrast, negative religious coping (NRC)
approaches have been shown to have an adverse effect on coping with
the stress.
Different instruments have been used to assess the coping strategies
used by caregivers of patients with schizophrenia to deal with the
caregiving stress (Magliano et al., 1995, 1998a, 1998b, 1999, 2000;
Hall and Docherty, 2000; Fortune et al., 2005; Roick et al., 2006;
Grandón et al., 2008; Hanzawa et al., 2008, 2010; Khajavi et al., 2011;
Hassan et al., 2011; Rexhaj et al., 2013). The use of different instru-
ments across different studies makes the findings difficult to compare.
However, a major focus of coping research has been its relationship
with various other variables like caregiver burden, psychological mor-
bidity/distress, expressed emotions, symptoms, social support, socio-
demographic variables of patients and caregivers, clinical variables,
and illness perception. Higher use of maladaptive coping is associated
with a higher perception of caregiver burden (Budd et al., 1998;
Scazufca and Kuipers, 1999; Magliano et al., 1999; Chakrabarti and
Gill, 2002; Chandrashekaran et al., 2002; Rammohan et al., 2002a;
Möller-Leimkühler, 2005; Roick et al., 2006; Chadda et al., 2007;
Grandón et al., 2008; Hanzawa et al., 2008, 2010; Khajavi et al., 2011;
Hegde et al., 2019), high expressed emotion (Scazufca and Kuipers,
1999), poor social support (Magliano et al., 1998a, 1998b) and higher
prevalence of psychological morbidity (Magliano et al., 1995; Scazufca
and Kuipers, 1999; Fortune et al., 2005). In terms of patient-related
outcomes, studies suggest significant correlations between the use of
coercion and "disorganized syndrome" and "psychomotor poverty syn-
drome" (Magliano et al., 1995). Longer illness duration of a patient's
illness has been associated with the caregiver's coping strategies of
positive communication and patient's social involvement (Magliano
et al., 1995). Living with the patient for a longer period is associated
with more often use of emotion-focused coping (Magliano et al.,
1998a).
Very few studies have assessed the religious coping among the
caregivers of patients with schizophrenia. Available data suggest that
caregivers employ religious beliefs or practices in maladaptive ways,
such as consider the illness of their loved ones as a punishment by God
(Pargament and Brant, 1998). Certain religious coping, such as colla-
borative coping (i.e., viewing oneself and God as sharing responsibility
to deal with adversity), is associated with better psychological adjust-
ment to stress (Murray-Swank et al., 2006). In contrast, adopting self-
directing (i.e., assuming complete responsibility without seeking any
assistance from God to resolve the problem) or deferring (i.e., placing
full responsibility on God to solve the problem) religious coping is as-
sociated with feelings of poor competence. Turning to religion as a
source of hope and comfort has also been shown to help the patient to
come in terms with the illness (Weisman et al., 2003).
Few studies from India have also investigated coping of caregivers
of patients with schizophrenia, by using different instruments
(Chakrabarti and Gill, 2002; Chandrashekaran et al., 2002; Rammohan
et al., 2002a; Chadda et al., 2007; Kate et al., 2013a, 2013b; Hegde
et al., 2019). However, the data on religious coping and its correlates
among the caregivers are less well understood, with only an occasional
study evaluating this aspect (Rammohan et al., 2002b). Religion plays
an integral role in the daily lives of people of India, and religious coping
appears to be a largely untapped, but a potentially highly useful tool in
the care of patients with schizophrenia and their families. Under-
standing the role of coping and religious coping in managing stress
2
Asian Journal of Psychiatry 54 (2020) 102219
further can incorporate the same in family-based interventions and
improve the outcome of the patients and caregivers. Thus, the current
study aimed to evaluate the coping strategies including religious
coping, used by the caregivers of patients with schizophrenia.
2. Methodology
This study was initiated after the approval from the ethics com-
mittee of the institute during the period of June 2013 to June 2014. The
cross-sectional study was carried out in a tertiary care hospital where
patients were recruited from the outpatient setting. The sample com-
prised 100 subjects diagnosed with schizophrenia and their primary
caregivers, chosen by purposive-random sampling from a pool of 200
eligible participants. The patients were required to fulfill the diagnostic
criteria of schizophrenia as per Diagnostic and Statistical Manual,
Fourth Edition (DSM IV) (American Psychiatric Association, 1994), as
evaluated by the Mini-International Neuropsychiatric Interview (MINI
6.0) (Sheehan et al., 1998). Other inclusion criteria were age 18–60
years, with illness duration of 2–10 years and must be accompanied by
a relative. Additionally, the patients with schizophrenia were required
to be clinically "stable". The clinical stability was defined as no clear-cut
exacerbation of symptoms in the previous 3 months on anamnestic
recall and scrutiny of medical records, continuing on the stable doses of
psychotropics in the previous 3 months, i.e., not ≥50% increase or
decrease in dosages of antipsychotic medications during this period.
Patients with intellectual disability, comorbid psychiatric disorders,
and organic brain syndrome were excluded. Additionally, the presence
of a diagnosis of chronic physical illness or comorbid psychiatric dis-
order in another family member in the same dwelling unit led to the
patient's exclusion.
A caregiver was defined as: a person, living with the patient and in-
timately involved in the care of the patient for a minimum duration of 1 year,
i.e., looking after her/his day to day needs, medication intake, accom-
panying the patient during the hospital visits, staying with the patient in case
the patient is admitted to the hospital, and maintaining liaison with the
hospital staff (Hegde et al., 2019). Such a person was also expected to be
giving a substantial amount of time with the patient (a minimum of one hour
per day will be required). The caregivers aged > 18 years, free from any
diagnosed physical or psychiatric morbidity (other than tobacco de-
pendence), and able to read Hindi formed part of the study. Caregivers
with any diagnosed chronic physical illness or mental disorder (except
tobacco dependence) were excluded.
Patients were assessed on the Positive and Negative Syndrome Scale
for Schizophrenia (PANSS) (Kay et al., 1987) and Global Assessment of
Functioning Scale (GAF) (American Psychiatric Association, 2000) to
assess residual psychopathology and level of functioning.
The caregivers were assessed on Ways of Coping Questionnaire
(WCQ), Brief Religious Coping Scale, and General Health Questionnaire
- 12 (GHQ-12) scales to evaluate coping, religious coping, and psy-
chological morbidity respectively.
2.1. Ways of coping questionnaire (WCQ) (Folkman and Lazarus, 1988)
WCQ is a 66 items scale, developed by Folkman and Lazarus
(Folkman et al., 1986). Each item has a brief description of a cognitive
and behavioral strategy for coping with stressful events. Accordingly,
the responders are asked to keep the specific stressful situation in mind,
experienced in the previous week, while answering the questionnaire.
Each item is rated on a 4-point scale with higher scores indicating more
frequent use of that particular strategy. The items of the scale are di-
vided into 8 subscales, i.e., confrontive coping, distancing, self-con-
trolling, seeking social support, accepting responsibility, escape-avoid-
ance, planful problem solving, and positive reappraisal. The addition of
the item scores obtains the score on each subscale. For comparison, the
weighted score is calculated for each subscale, by dividing the total
subscale score by the number of items for the subscale. WCQ has high
P. Rao, et al. Asian Journal of Psychiatry 54 (2020) 102219

reliability with Cronbach's alpha (α) rating of 0.89. In this study, the Table 1
Hindi translated and adapted version, used in one of the previous stu- Socio-demographic profile of patients [N = 100].
dies from India (Shah et al., 2017), was used. Socio-demographic variables Patients Mean Caregivers Mean
(S.D)/N (%) (S.D)/N (%)
2.2. Brief religious coping scale (brief RCOPE) (Pargament et al., 2011)
Age (in years) 36.17(11.59) 43.48(11.52)
Gender: Male/Female 52/48 55/45
The Brief RCOPE has 14 items grouped into PRC and NRC domains. Current marital status:Currently 62/38 91/9
PRC methods reflect a secure relationship with God and higher force, married/Currently unmarried
whereas NRC methods reflect underlying spiritual tensions and strug- Education – number of years 10.72(4.36) 10.11(3.89)
gles within oneself, with others, and with the divine. Cronbach’s alpha Education: Up to 10 years of 54/46 67/33
education/≥ 10 years of
value for the scale is ≥0.80. Both the subscales have high internal
education
consistency, concurrent validity, predictive validity, and incremental Employment: Currently employed/ 37/63 53/47
validity (Sherman et al., 2005; Pearce et al., 2006; McConnell et al., Currently unemployed
2006; Harris et al., 2008; Tsevat et al., 2009; Pargament et al., 2011). Socioeconomic status1 10
Upper
This scale has been validated in Hindi (Grover and Dua, 2019), which
Middle 81
has been shown to have high internal consistency, split-half reliability, Lower 9
test-retest reliability, and cross-language equivalence (Grover and Dua, Current income in Indian Rupees1
2019). Less than or equal to 7322/Greater 74/26 48/52
than 7322
Religion: Hindu/Non-Hindu 73/27
2.3. General health questionnaire -12 (GHQ-12) (Goldberg and Williams,
Family type: Nuclear/Non-nuclear 60/40
1988) Locality: Urban/Rural 56/44
Distance from the hospital (in 70.60(67.59)
The scale has 12-items, rated on a 2- point scale (better than usual Kilometers)
or same as usual are rated as 0, and less than usual or much less than Patients as a sole earning family 20
member
usual are rated as 1). The scale was translated to Hindi and has been Patients as head of the family 19
shown to have excellent reliability and validity (Gautam et al., 1987). A Only earning family member: Yes/ 24/76
cutoff score of < 2, is taken as an indicator of the absence of psycho- No
logical morbidity. Head of the family: Yes/No 40/60
Relationship with the patient
Statistical Package for Social Sciences, Fourteenth Version (SPSS-
Spouse 62
14) was used to analyze the data. Simple descriptive statistics, such as Parent 29
computation of mean and standard deviation, were used to analyze the Others2 9
continuous data. The discontinuous variables were analyzed in the form Time spent in caregiving hrs/day 2.72(0.81)
of frequency and percentages. Independent t-test and Mann Whitney U Duration of caregiving in years 11.68(8.22)
Supervision of medicines 87
values were used for comparison. Pearson's product-moment correla- Prior experience of caregiving 27
tion and Spearman’s rank correlation analysis was utilized to assess the
1
association between coping strategies and other variables. Given the As per the Kuppuswamy scale.
multiple relationships, Bonferroni's correction was utilized and a p- 2
Other caregivers include – 1 son and 8 siblings (6 brothers and 2 sisters).
value of ≤ 0.001 was considered to be statistically significant.
Table 2
3. Results Clinical Profile of the patient group [N = 100].
Clinical Variables Mean (SD)/N
The demographic profile of patients and caregivers are shown in
Table 1 and the clinical profile of the patients is depicted in Table 2. Schizophrenia subtype: Paranoid/Non- 52/48
paranoid1
When the different coping domains of WCC were compared with
Age at onset of illness 24.31(5.2)[range 15–35]
each other, by calculating the mean weighted score, seeking social The total duration of illness in months 142.32(100.0)[range 24–360]
support emerged to have the highest weighted mean score, and escape- Number of hospitalizations in the past 0.83(1.12)[range 0–6]
avoidance domain had the least mean weighted score (Table 3). The Number of visits in the past year 3.92(0.92)[range 2–6]
participants more frequently used the PRC subscale (mean: 11.42; SD- Percentage of visits with caregiver 75.79(20.54)[range 25–100]
The total duration of treatment in months 125.81(94.06)[range 12–350]
3.92) than the NRC subscale (mean: 1.72; SD- 2.73). The mean total
Total Chlorpromazine equivalent dose 502.64(362.95)[range
GHQ-12 score was 1.62 (range 0–6). Slightly less than half of the 100–1750]
caregivers had probable psychological disturbance and thus need of PANSS Positive subscale score 7.42(0.81)[range 7–10]
psychiatric care, indicated by a GHQ-12 score of ≥ 2 (Table 3). PANSS Negative subscale score 12.60(3.54)[range 7–24]
PANSS General psychopathology subscale score 19.51(2.80)[range 17–30]
PANSS total score 39.75(6.43)[range 31–64]
3.1. Correlates of coping Global Assessment of Functioning (GAF) score – 74.76(8.33)[range 52–90]
past year
Caregivers of employed patients more often used coping strategies
of seeking social support (< 0.001), accepting responsibility, planful 1-Non-paranoid schizophrenia includes – 6 patients of Hebephrenic schizo-
problem solving (< 0.001), and positive reappraisal (< 0.001), phrenia, 10 patients of Catatonic schizophrenia and 32 patients of un-
whereas caregivers of unemployed patients more often used escape- differentiated schizophrenia.
avoidance (< 0.001).
Type of schizophrenia had no relationship with more often use of lower level of residual psychopathology and better functioning in the
any type of coping used by the caregivers except that caregivers of patient and lower GHQ-12 score among the caregivers were associated
patients with non-paranoid subtype more often used escape-avoidance with more often use of coping mechanisms of seeking social support,
coping strategy (0.001). accepting responsibility, planful problem solving, and positive re-
The socio-demographic variables of caregivers did not have any appraisal and less often use of escape avoidance. Coping mechanisms
significant association with the type of coping strategies used. The such as confrontative coping, distancing and self-controlling, did not

3
P. Rao, et al. Asian Journal of Psychiatry 54 (2020) 102219

Table 3
Coping and psychological morbidity among the caregivers.
Variables Mean (SD) [range] Mean weighted score (SD)

Domains of Ways of Coping questionnaire

Confrontive coping 8.97(3.43)[range 3–17] 1.49 (0.57)
Distancing 10.18(3.07)[range 5–17] 1.69 (0.51)
Self-controlling 11.52(3.39)[range 2–20] 1.65 (0.48)
Seeking social support 11.23(3.42)[range 5–17] 1.87 (0.57)
Accepting responsibility 5.27(1.77)[range 1–10] 1.32 (0.44)
Escape-avoidance 8.66(5.12)[range 1–20] 1.08 (0.64)
Planful problem solving 9.91(2.44)[range 6–17] 1.65 (0.41)
Positive reappraisal 12.01(3.31)[range 6–19] 1.72 (0.47)
Brief RCOPE
PRC subscale 11.42(3.92)[range 3–17]
NRC subscale 1.72(2.73)[range 0–10]
Psychological morbidity in the caregivers
GHQ-12 total score 1.62(1.73)[range 0–6]
GHQ-12
Less than 2 55
Greater than or equal to 2 45

Table 4
Relationship between clinical variables of the patient, psychological morbidity in the caregiver and Coping strategies (as per WCQ and Brief RCOPE) of caregivers by
Pearson’s correlation [N = 100].
Variable Seeking social Accepting Escape-avoidance Planful problem Positive Positive RCOPE Negative RCOPE
support responsibility Correlation solving Correlation Reappraisal Correlation Correlation
Correlation Correlation coefficient (p- coefficient (p- Correlation coefficient1 (p- coefficient (p-
coefficient (p- coefficient (p-value) value) value) coefficient (p- value) value)
value) value)

PANSS-Positive symptoms −0.378* 0.345* −0.305* −0.356* 0.428*

score (< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) σ
PANSS-Negative symptoms −0.596* −0.392* 0.561* −0.546* −0.575* −0.419* 0.625*
score (< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) σ
PANSS-General −0.551* −0.319* 0.593* −0.493* −0.506* −0.345* 0.600*
Psychopathology score (< 0.001) (0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) σ
PANSS total score −0.596* −0.349* 0.601* −0.543* −0.564* −0.371* 0.671*
(< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) σ
GAF score-past year 0.712* 0.411* −0.702* 0.664* 0.687* 0.376* −0.732*
(< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) σ
GAF score-past month 0.731* 0.431* −0.711* 0.684* 0.722* 0.405* −0.786*
(< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) σ
GHQ total score −0.729* σ −0.472*σ 0.711*σ −0.695* σ −0.707*σ −0.396* 0.801*
(< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) (< 0.001) σ (< 0.001) σ

σ Spearman’s correlation.
* Correlation significant at the < 0.001 level.

have any significant correlation with residual psychopathology and Table 5

level of functioning of patients and psychological morbidity among the Association of coping strategies as assessed by WCQ and Brief RCOPE.
caregivers (Table 4). Variable Positive RCOPE Negative RCOPE
In terms of religious coping, caregivers of employed patients more Correlation coefficient1 Correlation coefficient (p-
often used PRC (< 0.001), while NRC was used more often by care- (p-value) value)
givers of unemployed patients (< 0.001) and the caregivers of patients
Confrontive coping 0.561* (< 0.001)
with lower income (< 0.001). Higher severity of psychopathology, i.e., Distancing 0.655* (< 0.001)
negative symptoms, general psychopathology, and PANSS total score Self-controlling 0.506* (< 0.001)
were associated with less frequent use of PRC and more frequent use of Seeking social support 0.402* (< 0.001) −0.775* (< 0.001)σ
NRC in the caregivers. Additionally, higher severity of positive symp- Accepting responsibility 0.212 (0.034) −0.418* (< 0.001)σ
Escape-avoidance −0.380* (< 0.001) 0.754* (< 0.001)σ
toms was associated with more often use of NRC.
Planful problem solving 0.354* (< 0.001) −0.723* (< 0.001)σ
Caregivers with higher income, used NRC (0.001) more frequently. Positive reappraisal 0.368* (< 0.001) −0.738* (< 0.001)σ
When the GHQ score of < 2 and ≥2 were used as categorizing the
caregivers into those without and with psychological morbidity it was σ Spearman’s correlation.
1
seen that those with psychological morbidity less often used seeking Pearson’s correlation coefficient used unless otherwise mentioned.
social support (< 0.001), accepting responsibility (< 0.001), planful * Correlation significant at the < 0.001 level.
problem solving (< 0.001) and positive appraisal (< 0.001) and more
often used escape avoidance (< 0.001) and NRC (< 0.001). A higher 3.2. Relationship between domains of WCQ and brief RCOPE
level of psychological morbidity among the caregivers was associated
with less frequent reliance on PRC and more frequent reliance on NRC It was seen that those caregivers who more frequently used PRC,
(Table 5). also more often used coping of all the domains of WCQ except that of
accepting responsibility and escape avoidance, with the use of the latter
being associated with lower use of PRC. Caregivers, who frequently

4
P. Rao, et al.
used NRC, also more often used escape avoidance and less often used
accepting responsibility, planful problem solving, seeking social sup-
port, and positive reappraisal (Table 5).
4. Discussion
When one looks at the available literature, there is a lack of con-
sensus on the frequency of use of problem and emotion-focused coping
with some studies reporting greater use of the former (Scazufca and
Kuipers, 1999; Chadda et al., 2007; Kate et al., 2013b) while others
report more use of the latter in caregivers of schizophrenia patients
(Mueser et al., 1997; Nehra et al., 2005). In the current study, coping
strategies, which could be classified as problem-focused, were the most
commonly used, whereas, escape-avoidance coping, which can be
considered as an emotion-focused strategy was the least used coping
strategies.
Previous studies from other parts of the world, based on ques-
tionnaires other than the WCQ have documented that caregivers often
rely on seeking information, positive communication, a patient's social
involvement, and resignation coping strategies (Magliano et al., 1995,
1999). A comparison of findings of our study, with these studies, re-
flects that the use of seeking social support domain of WCQ has some
similarities with the seeking information domain of the Family Coping
Questionnaire.
When the findings of the present study are compared with other
studies from India, there are more similarities than differences. One
study, that used FCQ to evaluate coping strategies, reported more often
use of coping like consulting doctors, talking to friends/family, and
seeking practical help, which is very similar to the seeking social sup-
port domain of WCQ (Nehra et al., 2005). The present study also sug-
gests that caregivers more often rely on problem-focused coping than
those of escape-avoidance and this finding is similar to previous studies
which have reported more frequent use of problem-focused coping
strategies than seek social support and avoidance strategies (Chadda
et al., 2007; Kate et al., 2013b). The present study does not support the
findings of a study from India, which reported using resignation as the
most commonly used coping strategy and lesser frequency of other
coping strategies as evaluated by FCQ (Chandrashekaran et al., 2002).
In terms of religious coping, PRC strategies were used more fre-
quently than the NRC strategies. Some of the previous studies have
evaluated religious coping in the caregivers of patients with schizo-
phrenia. Still, these have mostly relied upon self-designed ques-
tionnaires/instruments and have presented data about other coping
strategies or relationship of religious coping with caregivers’ outcome
in the form of depression and self-esteem (Rammohan et al., 2002b;
Weisman et al., 2003; Murray-Swank et al., 2006; Wasserman et al.,
2013). Hence, it is difficult to compare the findings of the present study
with the existing literature. The use of PRC by all the caregivers reflects
the importance of God and religion in Indian culture. NRC was used by
only a small group of patients and used less frequently than PRC. This
reflects that even in stressful situations, besides using other coping,
people in an eastern culture still rely on God for help and solution.
Most of the studies from India and around the world have reported
no significant association of coping strategies in caregivers with pa-
tients' socio-demographic profiles. In the present study, too, there were
only a few associations between the patients' socio-demographic profile
and various coping strategies. Caregivers of patients who were em-
ployed more often used adaptive coping (i.e., seeking social support,
accepting responsibility, planful problem solving, positive reappraisal)
and PRC. In contrast, caregivers of unemployed patients more often
used escape-avoidance and NRC. It is quite possible that besides the
patient's clinical variable, and response to treatment, the patient's em-
ployment status, and income may be an outcome of the use of more
adaptive coping strategies by the caregivers. Caregivers who more
frequently used adaptive coping strategies and PRC possibly create
opportunities for their patients to get more meaningfully employed and
5
Asian Journal of Psychiatry 54 (2020) 102219
integrated into society. On the other hand, more frequent use of escape
avoidance and NRC by the caregivers leads to a lack of proper social
integration of the patient into the society.
In our study, more frequent use of adaptive coping by the caregivers
was associated with lower level of psychopathology and better func-
tioning of the patient. The present study suggests that more frequent
use of PRC by the caregivers was associated with lower level of residual
psychopathology and better functioning of the patients. However, this
must not be interpreted as a cause and effect relationship, because, it is
also possible that better control of psychopathology is associated with
lower level of stress and hence, more frequent use of adaptive coping.
The reverse was right for a higher reliance on maladaptive coping like
escape avoidance. Previous studies which have used other scales for
assessment of coping also suggest similar findings (Magliano et al.,
1995; Mueser et al., 1997; Chakrabarti and Gill, 2002; Nehra et al.,
2005; Creado et al., 2006). One study from India reported a positive
association of resignation as a coping strategy and negative symptoms
in patients (Chandrashekaran et al., 2002). Studies also suggest that
more frequent use of coercion and decrease in talking to friends by the
caregivers is associated with higher dysfunction in the patients. In
terms of adaptive coping, a study reported that higher reliance on
problem-solving coping by the caregivers was associated with better
functioning of patients (Creado et al., 2006). Believing that the patient
was more in control has been shown to associated with more reliance
on collusion and positive communication coping and increasing social
involvement of the patient (Chakrabarti and Gill, 2002; Nehra et al.,
2005). In terms of religious coping, only one previous study has eval-
uated such a relationship, and findings are similar to the present study,
though not as robust as seen in this study. Rammohan et al. (2002b)
demonstrated a negative correlation of higher use religious coping of
caregivers with patients’ overall functioning.
Taken together, the present study and the existing literature suggest
that type of coping adapted by the caregivers can have an essential
bearing on patients' outcomes. Hence, the clinicians should devote
adequate time to assess the coping of caregivers, encourage them to use
adaptive coping, and discourage the use of maladaptive coping.
However, the findings of the present study should not be interpreted as
a cause-effect relationship because our study did not evaluate these
variables over time. It is also possible that patients had better symptom
control due to medications and other kinds of interventions. Hence,
they adapted to the more frequent use of adaptive and PRC.
In terms of caregiver’s outcome, higher use of maladaptive coping
like escape avoidance and NRC were associated with the presence of
psychological morbidity among the caregivers. The reverse was right
for the higher purpose of adaptive coping strategies. Existing literature
also supports the link between maladaptive coping and mental health
outcomes of the caregivers. Use of maladaptive coping strategies like
coercion, avoidance, self-blame, and resignation are associated with the
occurrence of psychiatric morbidities like anxiety, depression, etc. and
reduced quality of life in the caregivers (Magliano et al., 1995; Scazufca
and Kuipers, 1999; Fortune et al., 2005). On the other hand, strategies
that have been demonstrated to alleviate the distress of caregivers in-
clude seeking emotional support, active coping, acceptance, positive
reframing, and use of religion/spirituality (Fortune et al., 2005).
When the relationship of coping strategies as assessed by WCQ and
religious coping was evaluated, higher use of PRC was associated with
higher use of coping of all the domains of WCQ, apart from escape-
avoidance with which it had an inverse association. In contrast, NRC
was found to be associated with greater use of escape-avoidance and
lesser use of other adaptive coping skills. These associations possibly
suggest that religious coping and perhaps religious beliefs, play an es-
sential role in the use of different coping mechanisms by the caregivers
of patients with schizophrenia.
The limitations which must be kept in mind while interpreting the
results of our study include reliance on the only outpatient attending a
General Hospital Psychiatry Unit, clinically stable patients, and those
P. Rao, et al.
with illness duration of 2–10 years. Hence, the findings cannot be
generalized to the caregivers of patients attending other treatment
settings or not seeking treatment, caregivers of patients with a higher
level of symptoms, and longer duration of illness. In the present study,
assessment of coping was cross-sectional. Coping is understood as a
dynamic construct and is subject to change with time, before a stable
pattern is ste-in. Hence, longitudinal assessment of coping would be
more helpful in understanding the association of coping with the
caregiver and patient outcomes. Present study was limited to a group of
patients with schizophrenia, i.e., duration of illness being 2–10 years
and clinically stable at the time of assessment. As it is well known that,
schizophrenia is a heterogenous condition with different subtypes and
different stages of illness. Hence the findings of the present study may
not be applicable to the caregivers of patients of schizophrenia, who are
experiencing relapse, have first episode schizophrenia or have a long
duration of schizophrenia. Future attempts at the evaluation of coping
of caregivers should try to address these limitations.
To conclude, this study suggests that caregivers of patients with
schizophrenia use a mix of adaptive and maladaptive coping strategies,
including religious coping. The use of adaptive coping is associated
with better patient-related outcomes like a lower level of psycho-
pathology, better functioning, and more chances of being in paid em-
ployment. In terms of caregiver outcome, more reliance on adaptive
coping is associated with a lower level of psychological morbidity.
Whereas, more reliance on escape avoidance and NRC, which are
considered as maladaptive coping is associated with adverse outcomes
for both patients and caregivers.
Financial disclosure
None.
Declaration of Competing Interest
None.
Acknowledgement
None.
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