INTRODUCTION:

“Being a care giver is the most thankless role in the world. Everybody gives the patient some slack as they should, But the care givers has the stress of life and then you put a catastrophic illness on top of it, the stress goes through the roof.”

— Marcia Wallace

Mental illness refers to a group of disorders that cause severe disturbances in thinking feeling, and relating, often resulting in an inability to cope with the ordinary demands of life problems associated with severe behavioral disturbances such as violence, depression, anxiety they cause great distress to the person affected by producing a negative effects on their lives and the lives of their families.

Today Mental and behavioral disorders are common and affect more than 25% of all People at some time during their lives. One in four families is likely to have at least one member with a behavioral or mental disorder. It is estimated that mental disorders contribute a large share to the global disease burden and account for 33% of the years lived with the disability worldwide. It is estimated that two to three persons in every thousand adults suffer from serious mental illness such as affective disorders and schizophrenia. Care for severely mentally ill individuals may carry a heavy burden and stress particularly true for close family members such as Parents, who take care of their mentally ill children for long.¹

Family caregivers play a major role in providing care giving assistance to ill persons and their families. The effect of stress and anxiety on family members caring for an ill person in the family has been referred to as caregiver’s burden.

Caregiver’s burden is a multi dimensional phenomenon reflecting physical, psycho-emotional, social and financial consequences of caring for an impaired family member. Family members are acting as caregivers as the individual in the family of suffering from chronic diseases and continue his treatment at home. In many chronic diseases it places considerable burden for family caregivers who takes the sole responsibility in taking care of chronically mentally ill patients. Caregiver burden in mental illness can either be objective or subjective.

Objective burdens are defined as readily verifiable behavioral phenomena, e.g. negative patient symptoms; caregiver’s lives disrupted in terms of domestic routine, social activities and leisure; social isolation; and financial and employment difficulties. Subjective burdens comprise of emotional strain on caregivers, e.g. fear, sadness, anger, guilt, loss, stigma and rejection. The shift towards community care for patients with mental disease has resulted in transferring responsibility for day-to-day care of patients to their family members, which has lead to profound psychosocial, physical and financial burdens on patients’ family members.²

NEED FOR THE STUDY:

Mental illness is a psychological or behavior pattern generally associated with subjective distress or disability that occurs in an individual, and which are not a part of normal development or culture. The recognition and understanding of mental health conditions have changed once time and across culture.

In primitive societies mental illness was thought to be caused by evil spirit and the stigma continuous to be a huge problem for caring people with mental illness. As the time passed professionals and society understood the importance of the family members participating in the care of mentally ill in the hospital and at home. Living with and caring for an individual with a psychiatric disorder seems inherently stressful. Family members of psychiatric patients report a wide range of reactions to their situation. On the whole, these family members endorse significantly higher level of psychological distress than the general population. Mental illness has long been a problem in modern society. The treatment and Rehabilitation of clients with mental illness is heavy burden on family.

Studies have shown that in taking care of the mentally ill, the family caregivers have to face the stress and anxiety which includes: Feelings of insecurity sorrow and worry. Potential harm and aggression. Stigmatization by relatives and friends. Psychiatric emergencies and relapse. Dependence. Social isolation Fear of the future.

The study by Dr. Ricard revealed that the vast majority of caregivers were confronted by some level of distress. Indeed, this first study demonstrated that psychological distresses as well as problems related to sleep were significantly higher in caregivers Compared to the general population. It is estimated that 58% of the caregivers have elevated levels of psychological distress. It seems that having low socio-economic status is associated to ever higher levels of distress. Study also revealed that during a crisis, 42% of caregivers did not ask for help. The plain fact of not asking for help can come at a heavy price. To this effect, Dr. Ricard finds evidence suggesting that caregivers that were under the impression that their loved one’s state was not improving and who did not have access to exterior help, experienced a greater burden that was also related to long-term physical health problems. ³

STATEMENT OF PROBLEM:

“A study to assess the level of stress and anxiety among the family members of mentally ill patients at K.L.E.S Prabhakar Kore Charitable Hospital, Belgaum, Karnataka.”

OBJECTIVES:

· To find out the level of stress among the family members of mentally ill clients.

· To find out the level of anxiety among the family members of mentally ill clients.

· To find out the correlation between stress and anxiety among the family members of mentally ill clients.

Operational definitions:

1. Stress: - In this study stress refers to a biological, psychological, social, or chemical factor that causes physical or emotional tension and may be a factor in the etiology of certain illness.⁵

2. Anxiety: - Anxiety is an emotional or physiological response to known or unknown causes that may range from a normal reaction to extreme dysfunction, affect decision-making and the quality of life.⁶

3. Family Members: - It refers to a person who had an intimate personal relationship or who is relative of the mentally ill client age group of 20 to 60.

4. Mental Illness: - Mental and behavioral disorders are understood as clinically significant conditions characterized by alterations in thinking, mood(emotions) or behavior associated with personal distress and/or impaired functioning.(WHO 2001).⁷

Hypothesis:

H₁- There will be a positive correlation between stress and anxiety level among the family members of mentally ill patient.

Assumptions:

There may be high level of stress and anxiety among the family members of mentally ill patients.

REVIEW OF LITERATURE:

Review of literature involves the systematic identification location, scrutiny of the written materials that contain information on research problem. It is an extensive systematic solution of potential source of pre work, fact and finding of the chosen problem. The present literature review has contributed good background material, helpful metrology and relevant insights to the study.

A study was conducted in 1982; Family burden is the emotional and economic strain that family members experience when a relative is discharged from a mental hospital and returns home. Since World War II the length of hospital stays has declined steadily, and deinstitutionalization has promoted community care of the mentally ill. Studies suggest that more than 65 per cent of discharged mental patients return to their families. Family burden is a complex problem that seriously affects the treatment of chronic mental patients. The author discusses the scope of family burden and outlines some practical solutions.⁴

A study was conducted in 1989 on the relationship between care giving stress and elders' symptoms of mental impairment has focused primarily on cognitive incapacity. This research expands the symptoms of mental impairment to include caregivers' reports of problems in elders' social functioning and the presence of disruptive behavior, in addition to the traditional measure of cognitive incapacity. Results from a study of 614 families living with and caring for an impaired elder show cognitive incapacity to have a less important direct effect on caregiving stress than disruptive behavior and impaired social functioning. Cognitive incapacity does have an important indirect effect through its influence on disruptive behavior and social functioning.⁵

A study was conducted in 1989; Family members of seriously mentally ill persons were interviewed to determine their satisfaction with services received through a countywide service system based on the community support program (CSP) model developed by the National Institute of Mental Health. Interviews with 56 family members indicated that a majority were dissatisfied with various aspects of the service system. Multiple regression analysis revealed that significant contributors to family satisfaction were sex of respondent, type of relationship to family member, age at onset of illness, and time since onset of illness. Interaction with a case manager, specifically interaction involving emotional support for families, was the strongest factor explaining family satisfaction. That finding confirms the central role of the case manager in the delivery of CSP services.⁶

A study was conducted in 1995; Among 225 family members participating in a study of psycho educational interventions, 39% of the variance in subjective burden was explained by the severity of stressors related to the relative's illness and by mediators related to social support and coping capabilities. Interventions directed toward improving self-efficacy and coping strategies may be important mediators of subjective burden.⁷

A study was conducted in 2001; this study explores the relationship between direct support from family members and friends and substance use outcomes for people with co-occurring severe mental illness and substance use disorders. Data are from a 3-year randomized trial of 203 patients in treatment for dual disorders. Informal (family) caregivers for 174 participants were asked about economic assistance and direct care that they provided to participants. Care giving hours were significantly associated with substance use reduction but not with cumulative substance use. Informal support was not associated with changes in psychiatric symptoms. The findings suggest that direct family support may help people with dual disorders to reduce or eliminate their substance use. Further research is needed to confirm this connection and to establish the mechanisms by which support is useful.⁸

METHODOLOGY:

This chapter includes research approach, research design and settings of the study, population, sampling, research technique, research tool, data collection process and plan for data analysis.

Research approach

Research approach tells the researcher from whom the data is to be collected, when the data is to be collected and how to analyze them. For the present study survey approach was found to be appropriate.

Research Design

A design is a blue print for conducting the study that maximizes control over factors that could interfere with the validity of the findings. The design of a study is the end result of a series of decisions made by the researcher concerning how the study will be implemented. The investigators selected the non-experimental descriptive design to assess the level of anxiety and stress among the family member of mentally ill patients was considered as an appropriate one.

Variables

The variables for the present study are;

Research or study variables:

Levels of stress and anxiety.

Attributed Variables:

Personal characteristics which include Age, Gender, Religion, Education, Type of family, Family income, Place of residence, Type of mental illness.

Research Setting

The study was conducted in Psychiatric IPD/OPD of K.L.E.S Dr. Prabakar Kore Charitable Hospital, Belgaum, Karnataka.

Research Population

According to Polit and Hungler, population is defined as the entire aggregation of cases that met the designated set of criteria. In this study population refers to all family members of mentally ill patients at K.L.E.S Dr. Prabhakar Kore Charitable Hospital, Belgaum, Karnataka.

Sample Size

The study consists of 30 family members of mentally ill patients who fulfilled sampling criteria.

Criteria for Selecting The Sample

The criteria for sample selecting were based on availability, practical concern, design and the sample ability to participate in the study. The study has two criteria namely inclusion and exclusion criteria.

(I) Inclusion Criteria

a) The family members of mentally ill patients, age group between 20-60 years.

b) Family members of mentally ill patients who are willing to participate in the study.

(II) Exclusion Criteria

a) Family members who are not co-operative.

b) Family members who are not available at the time of data collection

Sampling Technique

Non- probability, convenient sampling technique was used to select the sample for this study. The sample selection was based on the inclusion and exclusion criteria.

Development of tool

After an extensive literature review the tool was selected. The investigators used standardized, four point stress and anxiety inventory consists of 14 items on Anxiety and 14 items on Stress. Interview method was used to collect the data from samples. The following steps carried out in preparation of tool.

Literature review

The tool has two sections namely section A and section B

Section A: Demographical data

Section B: Standardized Anxiety and Stress Scale from Australian centre for Posttraumatic Mental Health.

Description of the tool

The tool is consisting of:

1. Demographical data consist of 8 items.

2. 14 items on Anxiety and 14 items on Stress.

Method of data

Data collection was done between 3/06/2013 to 13/06/2013, by interview method. After obtaining the permission from Principal and Medical Superintendent of K.L.E.S Dr. Prbhakar Kore Charitable Hospital, Belgaum, and Karnataka.

The method used for data collection was as follows:

a. The researcher investigators introduced themselves and explained the purpose of the study to the family members of the mentally ill patients.

b. The demographic data was collected.

c. The assessment of subject’s through Interview method.

d. Data collected was then tabulated and analyzed.

Data analysis plan:

The data obtained were analyzed in terms of objectives of the study using descriptive and inferential statistics. The plan of the data analysis was developed under the excellent direction of the experts in the field of nursing and statistics.

The plan of the data analysis was as follows.

1. Organize the data on master data sheet.

2. Computer frequency, percentage, means, standard deviation and range to describe the data.

3. Classification of stress and anxiety scores as follows

0 Did not apply to me at all

1 Applied to me to some degree, or some of the time

2 Applied to me to a considerable degree, or a good part of time

3 Applied to me very much, or most of the time

4. Use of inferential statistics to draw the conclusions.

To interpret the level of stress and anxiety were categorized as:

	Anxiety	Stress
Normal	0 - 7	0 – 14
Mild	8 – 9	15 – 18
Moderate	10 – 14	19 – 25
Severe	15 – 19	26 – 33
Extremely Severe	20+	34 +

This chapter on research methodology has thus described about data various activities carried out and planned by the research investigators during the course of our project.

Analysis and interpretation of data

The data obtained were analyzed in terms of the study using descriptive and inferential statistics. The plan of the data analysis was as follows

1) Organize the data on master data sheet.

2) Computer frequency, percentage, mean, mode, standard deviation, range to describe the data.

3) Clarify the anxiety and stress score.

Analysis is the process of organizing and synthesizing data so as to answer research question and test hypothesis.

Analysis andinterpretation of the data was based on the following objectives and framed for the study.

The data was analyze according to objectives of study which were

· To find out the stress among the family members of mentally ill clients.

· To find out the anxiety among the family members of mentally ill clients.

· To find out the correlation between stress and anxiety among the family members of mentally ill clients.

Hypothesis

H₁- There will be a positive correlation between stress and anxiety among the family members of mentally ill patient.

The data was collected through:

Structured interview schedule to assess the level of stress and anxiety among family members of mentally ill patients.

The data was analyzed by using descriptive and inferential statistics.

Presentation of data

The data is presented by using following section.

Section A: Findings related to Demographical data

Section B: Findings related to Anxiety and Stress Scale from Australian centre for Posttraumatic Mental Health.

Section C: Findings related to correlation between Anxiety and Stress.

Section A: Findings related to Demographical data.

Table 1: Frequency and percentage distribution of family members of mentally ill patients according to the demographic variables. N=30

SL.NO	DEMOGRAPHIC VARIABLES	FREQUENCY	PERCENTAGE
1.	Age (In Years)
	a) 21 – 30 years	4	13.33%
	b) 31 – 40 years	9	30%
	c) 41 – 50 years	13	43.34%
	d) 51 – 60 years	4	13.33%
2.	Gender
	a) Male	18	60%
	b) Female	12	40%
3.	Religion
	a) Hindu	27	90%
	b) Muslim	3	10%
	c) Christian	-
	d) Jain	-
4.	Education
	a) Illiterate	5	16.67%
	b) Primary	10	33.33%
	c) Secondary	10	33.33%
	d) PUC	2	6.67%
	e) Graduate	3	10%
5.	Type of family
	a) Nuclear	14	46.67%
	b) Joint	16	53.33%
	c) Extended
6.	Family Income (per month)
	a) <10000	26	86.67%
	b) >10000	4	13.33%
7.	Place of residence
	a) Rural	23	76.67%
	b) Urban	7	23.33%
8.	Type of mental illness
	a) Acute	10	33.33%
	b) Chronic	20	66.67%

Figure 10: Reveals that in the area of Stress mean was 23.3, Median 22.5, Mode 20.9, S.D 3.26 and range of score was 14. Where as in the area of Anxiety mean was 15.3, Median 14, Mode 11.4, S.D 3.53, and range of score was 16.

Section C: Findings related to correlation between Anxiety and Stress.

According to Karl Pearson’s formula there is a positive correlation (0.19) between stress and anxiety among the family members of mentally ill patients. Hence it is concluded that the stated hypothesis (H₁) has been accepted.

DISCUSSION:

This chapter deals with major findings of the study. The present study was undertaken to evaluate the level of Stress and Anxiety among the family members of the mentally ill patients at K.L.E.S Dr. Prabakar Kore Charitable Hospital, Belgaum, Karnataka.

The major findings of the study are organized under the following Headings:

1. Findings related to Demographical data

2. Findings related to Anxiety and Stress Scale from Australian centre for Posttraumatic Mental Health.

3. Findings related to correlation between Anxiety and Stress.

Section A: Findings related to social demographic variables of family members of mentally ill patients.

Ø Majority (43.34%) of the subject belongs to 41- 50 years of age; maximum (30%) of the subject belongs to 31-40 years of age while minimum (13.33%) belongs to 21-30 years and 51-60 years of age.

Ø Majority (60%) of the subjects are males, while minimum (40%) are female.

Ø Most (90%) of the subjects belongs to Hindu and (10%) belongs to Muslim.

Ø Majority (33.33%) of the subjects have primary and secondary education, maximum (16.67) of the subjects are illiterate while minimum (6.67%) have PUC education and (10%) of the subjects are graduates.

Ø Majority (53.33%) of the subjects belongs to joint family, while minimum (46.67%) belongs to nuclear family.

Ø Majority (86.67%) of the subject’s family income is below Rs 10000, while the minimum (13.33%) have above Rs. 10000.

Ø Majority (76.67%) of the subjects are from rural area, while minimum (23.33%) are from urban area.

Ø Majority (66.67%) of subject’s patient are suffering with chronic mental illness, while the minimum (33.33%) are suffering with acute mental illness.

Section B: Findings related to the level of Stress and Anxiety in family members of mentally ill patients by using Interview Method.

Ø Among the 30 samples majority 53.34%(16) of subjects have moderate level of Anxiety, maximum 33.33% (10) of subjects have severe level of Anxiety and minimum 13.33% (4) of subjects have extremely severe level of Anxiety.

Ø In interview method majority 63.33% (19) of subjects has moderate level of Stress, maximum 30% (9) of subjects have severe level of Stress and minimum6.67% (2) of subjects have mild level of stress.

Section C: Findings related to correlation between Anxiety and Stress.

CONCLUSION:

Based on the findings of the study, the following conclusions have drawn.

Ø The data has been collected through the interview method, by using standardized scale for the assessment of stress and anxiety.

Ø Level of stress and anxiety are assessed among the family members of mentally ill patients and classified.

Ø Obtained scores analyzed and found correlation between the stress and anxiety among the family members of mentally ill patients by using Karl Pearson’s formula.

IMPLICATION:

The finding of the study had varied implications in different areas of Nursing practice, Nursing Administration, Nursing Education and Nursing Research.

Nursing Practice:

Considering the factors which causes the burden on the family members the nurse can contribute in preventing psychological or emotional distress among the family members of the mentally ill patients. Since nursing personnel will come in contact with the family members of mentally ill patient in community settings or in hospitals can find out the burden and proper interventions are guided.

Nursing Administration:

Nursing administrator can focus on organizing the workshop, seminars and in-service education for the staff nurse to gain more advanced skills to manage family members of the mentally ill clients. Workshop can be conducted on enhancing the coping strategy which helps to reduce their psychological distress among the family members.

Nursing Education:

The changing values of the society, health care and development advanced technology etc influenced the individuals’ needs. So it is necessary to take special concern about the family members of the mentally ill clients, psychological and emotional problems are discussed in the curriculum, which will enhance the nurses to provide comprehensive care to the client and family members.

Nursing Research:

Nurses can also under take the study to assess burden of the family members in caring of mentally ill patients, because the family member’s burden is least focused. In Indian there are few studies on it. So the investigation has to be carried out on larger population and different aspects can be assessed to understand and to provide holistic care to the patient as well as family members of mentally ill client.

LIMITATION OF THE STUDY:

1. No broad generalization could be made due to the small size of sample and limited area of setting.

2. The study did not use any control group.

3. No attempt was made to control extraneous variable.

SUMMARY:

This chapter presents a Summary of the study. The aim of the study was to assess the level of Stress and Anxiety among the family members of the mentally ill patients at K.L.E.S Dr.Prabhakar Kore Charitable Hospital, Belgaum, Karnataka.

The Objectives of Study Were to;

· To find out the stress among the family members of mentally ill clients.

· To find out the anxiety among the family members of mentally ill clients.

· To find out the correlation between stress and anxiety among the family members of mentally ill clients.

The Study Attempted To Examine Research Hypothesis:

H₁- There is a positive correlation between stress and anxiety among the family members of mentally ill patient.

Assumptions

There may be high level of stress and anxiety among the family members of mentally ill patients.

FINDINGS: