Since family caregiving became a widely studied topic in the early 1980s, most research has emphasized caregiving burden and the potential negative effects of caregiving stress on mental and physical health. Psychologists and others involved in clinical practice most often see caregivers who are seeking help because they are experiencing high levels of strain in the caregiving role, and these caregivers often report high levels of burden, stress and disruption of their own well-being and social activities.
Strain Associated with Providing Caregiving Assistance
Multiple population-based studies indicate that many family caregivers report little strain associated with providing caregiving assistance. Schulz and Beach (1999) found that 44 percent of the spouse caregivers in their sample reported “no strain” in association with caregiving tasks. Using similar questions for both spouse and non-spouse caregivers, Roth and colleagues (2009) found that 33 percent of caregivers reported “no strain” and 50 percent reported “some strain,” while only 17 percent reported “a lot of strain.” A recent survey by the National Opinion Research Center (2014) found that 83 percent of caregivers viewed it as being a positive experience. Many caregivers experience both positive experiences and some strain simultaneously (Beach et al., 2000; Harmell et al., 2012). Lawton and colleagues' (1991) two-factor model suggests that caregivers may experience both emotional distress and psychological satisfaction and growth, effects that are not incompatible.
Analyses of Mental and Physical Health Effects
Meta-analyses of the physical and mental health effects of caregiving have shown higher levels of depression and physical health problems in caregivers when compared with noncaregivers (Pinquart & Sorensen, 2003; Vitaliano, Zhang & Scanlon, 2003). In Pinquart and Sorensen's review, effect sizes (differences between caregivers and noncaregivers) for all studies were .58 Standard Deviation Units (SDUs) for measures of depression and .18 SDUs for measures of physical health, with caregivers having higher depression and worse health. Most of these studies used nonrepresentative samples of caregivers and noncaregivers drawn from clinics, support groups and recruitment of volunteers. These effect sizes were considerably smaller for studies that used representative community samples (e.g. from population based studies), with these effect sizes being .26 SDUs for depression and .09 SDUs for physical health. A recent study of 5,159 caregivers and 37,940 demographically equated noncaregivers found effect sizes of only .13 SDUs for caregiver depression and .01 SDUs for physical health. This study also found that caregivers who reported no strain (33 percent of caregivers) had lower depression than noncaregivers, and that only the 18 percent of caregivers reporting high strain had elevated depression compared with noncaregivers (Roth et al., 2009). These highly strained caregivers had depression scores over twice as high as noncaregivers (Roth et al., 2009), highlighting the importance of examining caregivers' subjective experiences of strain. Thus while caregivers report more distress than noncaregivers, the extent of these differences depends on the populations studied.
A widely cited, landmark population based study of caregiving (Schulz & Beach, 1999) reported that spouse caregivers who reported strain were at risk for premature mortality. This study has been cited incorrectly by many scholars, policy groups and on caregiver web sites to suggest that all caregivers are at risk for heightened mortality (Brown & Brown, 2014; Roth et al., in press). Five more recent population based studies of caregiving and mortality, all with larger sample sizes than Schulz & Beach (2009), have reported the opposite effect, with caregivers living longer than noncaregivers (See Roth et al. in press for a review). Biomarker studies comparing caregivers and noncaregivers (see Lovell & Wetherell, 2011 for a review) often report that caregivers have abnormalities in measures of endocrine and immune system function, but nearly all of these studies have used small convenience samples and focused on dementia caregivers (Roth et al., in press). Thus evidence is currently mixed as to whether caregiving has generally negative effects on objective indicators of health.
Highly Strained Caregivers: Older Adults and Women
This does not minimize the importance of examining possible negative health effects on highly strained caregivers. Older adults in caregiver roles may be particularly vulnerable because caregiving demands may tax their health and physical abilities and compromise their immune response systems, and the stress associated with caregiving can exacerbate existing chronic health conditions (Navaie-Waliser et al., 2002). Older caregivers may also be at increased risk for unintentional injuries such as falls, cuts, scrapes and bruises that can range from minor to serious (Hartke et al., 2006). There is also evidence that women take on more caregiving tasks, report more care recipient problems and experience more distress due to caregiving than male caregivers (Pinquart & Sorensen, 2005; Yee & Schulz, 2000). Due to the demands on their time, caregivers may be less likely to engage in preventive health behaviors than non-caregivers and thus neglect their own health (Schulz, 1997) and may be at increased risk for medication use (Vitaliano, Zhang & Scanlon, 2003). Dementia caregivers report more stress and depression than other caregivers (Ory et al., 1999). There is also evidence that family caregivers in certain caregiving scenarios — for example, those caring for a loved one with a brain injury — may be more likely to encounter verbal abuse from the care recipient or a family member (Erosa, Elliott, Berry & Grant, 2010; Stern, 2004).
Beyond Mental and Physical Health Effects
The potential negative effects on caregivers can also extend well beyond mental and physical health effects. Caregivers, particularly younger caregivers, often experience disruptions to their education, putting school on hold or dropping out entirely, which can impact their future career and earnings (National Alliance on Caregiving, 2005). Caregiving can also result in considerable financial strain, and can cause difficulties in other roles such as marriage and employment (National Alliance for Caregiving, 2009; National Opinion Research Center, 2014).
Conclusion
In summary, population based studies show that many caregivers do not report high levels of strain, cope successfully with caregiving, report many psychological benefits from caregiving, and may even experience improved health and reduced mortality because of their caregiving experience. However there are clearly subgroups of caregivers that report high levels of strain, experience heightened depression, and who may show negative health effects from caregiving. Caregiving strain is often worsened by certain kinds of caregiving demands (dementia and end-of-life care) and in circumstances where caregivers do not have enough resources (knowledge, skills, social support, respite, and community services) and can be overwhelmed. Clinicians in many settings are most likely to see these highly strained caregivers, and should be prepared to address their considerable psychological, social, and health needs, while also understanding that caregivers may feel pride, a sense of purpose, and other benefits from their caregiving activities.
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