Caregivers’ depressive symptoms and eating disorder severity in adults with anorexia and bulimia nervosa

Abstract

Background:

Negative affectivity of caregivers has been linked to difficulties in the caregiver-patient relationship and it is assumed to contribute to the maintenance of eating disorder (ED) symptoms.

Aims:

The present study investigated the relationship of patients’ ED symptom severity to patients’ and caregivers’ depressive symptoms, and caregivers’ involvement in a mixed sample of adult inpatients with anorexia (AN) and bulimia nervosa (BN), as well as their caregivers.

Method:

The Eating Disorder Examination and Beck Depression Inventory (BDI) were administered to 55 adult ED patients (26 AN and 29 BN), and the BDI as well as the Involvement Evaluation Questionnaire were filled in by one caregiver of each patient.

Results:

Our results showed caregivers’ depressive symptoms to be significantly related to patients’ ED symptom severity, however depressive symptoms and ED symptoms of patients were not related. No connection of involvement of caregivers and ED severity of patients was found. AN and BN patients did not significantly differ on ED severity or depressive symptoms. Caregivers of AN and BN patients did not differ significantly on depressive symptoms and involvement.

Conclusions:

Our results support the importance of mental health support for caregivers of adults with AN and BN.

Keywords

Eating disorders anorexia nervosa bulimia nervosa depression involvement caregiver

Introduction

Adult eating disorder (ED) patients and their caregivers show a high prevalence of depressive symptoms (Treasure et al., 2020; Zabala et al., 2009). Caring for someone with anorexia nervosa (AN) is a risk factor for depression and other difficult mental states (Stefanini et al., 2019). Goddard et al. (2013) found evidence for an indirect connection between caregivers’ distress and AN patients’ ED symptoms through patients’ distress. However, it is unclear, if caregivers depressive symptoms can be directly associated with patients’ ED severity in adults and if this is applicable in various ED types.

Caregivers of ED patients report high involvement in comparison to those of patients with other severe mental disorders (Martín et al., 2015) although adults often refuse to involve their caregivers in the therapy (Slater et al., 2015). Involvement and depressive symptoms are significantly linked in caregivers of ED patients (Kocsis-Bogar et al., 2023; Padierna et al., 2013). However, it is not clear, if caregivers’ involvement and patients’ symptom severity are connected.

In the present study, the following hypotheses were formulated: (1a) A significant positive connection of caregivers’ and patients’ depressive symptoms and (1b) a positive connection of both of these with patients’ ED severity were expected. (2) A significant connection of caregivers’ involvement with patients’ ED symptoms was expected.

Method

Human rights statement

Ethical approval was obtained from the Research Ethics Committee of the Medical University of Vienna. All procedures in this study involving human participants were in accordance with the 1964 Helsinki declaration and its later amendments.

Participants

Fifty-five inpatients (26 AN and 29 BN) of the Clinical Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna were included. For each patient one caregiver with the most significant supporting role – the so-called ‘key relative’ – was invited in the study. Data collection, as well as inclusion and exclusion criteria, are described in more detail in Kocsis-Bogar et al. (2023).

Measures

Eating Disorder Examination (EDE; Hilbert & Tuschen-Caffier, 2006, sample α = .91), Beck Depression Inventory (BDI; Beck et al., 1961, sample α = .84), and Involvement Evaluation Questionnaire (IEQ; Van Wijngaarden et al., 2000, sample α = .85) were applied.

Statistical analysis

IBM SPSS 26 was used for data analysis. Missing values were not substituted. AN and BN patient and caregiver groups were compared via Student’s t-test for dimensional and χ² test for categorical variables. Hypothesis 1a was tested via Pearson correlation analysis. Hypothesis 1b and 2 were investigated via hierarchical multiple linear regression analysis adjusted for the ED diagnosis entered in the first block. Patients’ depressive symptoms were entered in the second, caregivers’ depressive symptoms in the third, and caregivers’ involvement in the fourth block. Patients’ age and duration of illness were not included due to their correlation with ED severity. Patients’ sex as was not included because of the predominance of women. Normal distribution (Kolmogorov-Smirnov, p > .84) and homoscedasticity (Breusch-Pagan test, p = .61) were checked for the variables included in the regression analysis. Level of significance was set at p < .05. Bonferroni correction was applied.

Results

Descriptive values of the sample

AN and BN patients were not significantly different regarding age, sex, length of illness, BDI or EDE total scores, restraint or eating concern, and after Bonferroni correction regarding weight concern either. BN patients had significantly higher BMI and shape concern. Caregivers of AN and BN patients did not differ regarding their age, sex, depressive symptoms, and involvement (Table 1).

Table 1.

Descriptive variables of the whole sample (N = 55) and comparison of AN (n = 26) and BN (n = 29) patients.

	Whole sample	AN	BN	Statistics	p
	Patients
	M (SD)	M (SD)	M (SD)
	N = 55	n = 26	n = 29
Age	29.47 (9.11)	27.62 (8.35)	31.14 (9.58)	t(53) = −1.45	.15
Sex	Female: 46/83.6%	Female: 22/84.6%	Female: 24/82.80%	χ² = 0.04	.57^a
Duration of illness	10.11 (8.10)	8.80 (6.64)	11.30 (9.17)	t(53) = −1.15	.26
Beck Depression Inventory	27.54 (11.73)	25.90 (13.17)	28.92 (10.43)	t(46) = −0.88	.38
Body-Mass-Index	22.19 (8.71)	16.66 (2.81)	26.96 (9.27)	Welch’ F (33.850) = −5.69	<.001
EDE total mean score	3.05 (1.50)	2.67 (1.67)	3.37 (1.28)	t(51) = −1.73	.10
EDE Restraint	2.57 (1.74)	2.65 (1.84)	2.50 (1.66)	t(53)= 0.32	.75
EDE Eating concern	2.59 (1.65)	2.23(1.77)	2.89 (1.52)	t(52) = −1.47	.15
EDE Weight concern	3.22 (1.83)	2.68 (2.00)	3.70 (1.53)	t(53) = −2.13	.04
EDE Shape concern	3.62 (1.81)	2.75 (1.76)	4.38 (1.51)	t(52) = −3.65	.001
	Caregivers
	M (SD)	M (SD)	M (SD)
Age	43.87 (13.61)	46.08 (12.64)	41.90 (14.35)	t(53) = 1.14	.26
Sex	Female: 35, 63.6%	Female: 9/73.10%	Female: 16/55.20%	χ² = 1.90	.26
Beck Depression Inventory	8.08 (6.06)	9.33 (5.79)	6.92 (6.18)	t(48) = 1.42	.16
Involvement Evaluation Questionnaire	23.18 (12.62)	24.56 (10.94)	22.04 (13.93)	t(49) = 0.71	.48

Note. EDE = eating disorder examination.

Fisher’s exact, bold: significant after Bonferroni correction p = .004.

Connection of patients’ and caregivers’ depressive symptoms, caregivers’ involvement, and patients’ ED severity

Depressive symptoms of patients and caregivers were not significantly associated (r = −.07, p = 0.64, N = 43). Regarding the hierarchical regression analysis, only model 3 reached significance, according to which only caregivers’ depressive symptoms were significantly linked to patients’ ED severity, whereas the diagnosis and patients’ depressive symptoms remained insignificant. This was the only model with a significant amount of change. Adding caregivers’ involvement did not result a significant further change and model 4 remained non-significant (Table 2).

Table 2.

Hierarchical regression model of factors associated with ED severity in the sample of AN and BN patients (N = 55).

Model fit	Predictors	β	t	p	Tolerance	VIF
Model 1
R² = .05, F = 1.83, p = .18	Diagnosis of AN or BN	.21	10.35	.18	1.00	10.00
Model 2
R² = .11, F = 2.18, p = .13 ∆R² = .06, ∆F = 2.46, p = .13	Diagnosis of AN or BN	.19	10.23	.23	0.99	10.01
R² = .11, F = 2.18, p = .13 ∆R² = .06, ∆F = 2.46, p = .13	Patients’ BDI	.25	10.57	.13	0.99	10.01
Model 3
R ² = .21, F = 3.23, p = .03 ∆R² = .11, ∆F = 4.86, p = .03	Diagnosis of AN or BN	.23	10.52	.14	0.98	10.02
	Patients’ BDI	.26	10.74	.09	0.99	10.01
	Caregivers’ BDI	.33	20.21	.03	0.99	10.01
Model 4
R² = .21, F = 2.35, p = .07 ∆R² = .00, ∆F = 0.006, p = .99	Diagnosis of AN or BN	.23	10.50	.14	−0.97	10.02
	Patients’ BDI	.26	10.72	.09	0.99	10.01
	Caregivers’ BDI	.32	10.91	.06	0.79	10.27
	Caregivers’ IEQ	.01	00.07	.94	0.79	10.27

Note. AN = anorexia nervosa; BN = bulimia nervosa; BDI = Beck Depression Inventory; IEQ = Involvement Evaluation Questionnaire. Bold value represent the significant results.

Discussion

The main finding of the present study was the direct relationship between caregivers’ depressive symptoms and patients’ ED severity. This can be interpreted in terms of the cognitive-interpersonal model of negative emotions in family members in association with ED symptoms (Treasure & Schmidt, 2013). Caregivers’ burden can compromise their relationship with the patient (De La Rie et al., 2005) which can in turn contribute to more severe ED symptoms (Treasure et al., 2020). Contrary to Goddard et al. (2013), patients depressive symptoms had no significant connection to ED severity or caregivers’ depressive symptoms, possibly because of patients’ relatively high and caregiver’s only slightly elevated BDI scores. Unlike Goddard et al. (2013), the present sample included BN and AN patients living mostly independently of their caregivers with a higher mean age. A possible explanation for the lack of connection between patients’ depressive and ED symptoms is that chronic depressive symptoms in ED patients are comorbid but not directly connected to ED symptom severity but other factors such as quality of life (Martín et al., 2017).

No connection between caregivers’ involvement and patients’ ED severity was found. Contrary to expressed emotions or accommodating (Goddard et al., 2013), involvement has some positive (such as urging and supervision) aspects from the patients’ point of view which can be experienced as caring. Further, involvement was measured by a self-report questionnaire and thus may not correspond to patients’ perception of their caregivers’ involvement.

It is a cross-sectional examination, which makes it impossible to draw causal conclusions. The limitations of it are described in detail in Kocsis-Bogar et al. (2023). Our results support the importance of considering the needs of caregivers of adult ED patients in the treatment (Treasure et al., 2020) to reduce burden for caregivers (Hibbs et al., 2015) as well as health care services (Treasure et al., 2020).

Footnotes

Acknowledgements

The authors are grateful to all the patients and caregivers for their participation as well as to the medical, nursing, and therapy team of the hospital for their support.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project was supported by the Medical-Scientific Fund of the Mayor of Vienna (project number: 09032)

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work, no AI or AI-assisted technologies were used.

ORCID iD

Krisztina Kocsis-Bogar

Data availability statement

The data underlying thsis article will be shared on reasonable request to the corresponding author.

References

Beck

A. T.

Ward

C. H.

Mendelson

Mock

Erbaugh

(1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571. https://doi.org/10.1001/archpsyc.1961.01710120031004

De La Rie

S. M.

Van Furth

E. F.

De Konig

Noordenbos

Donker

M. C. H.

(2005) The quality of life of family caregivers of eating disorder patients. Eating Disorders, 13, 345–351. https://doi.org/10.1080/10640260591005236

Fairburn

C. G.

Cooper

(2003). The eating disorder examination (12th ed.). In Fairburn

C. G.

Wilson

G. T.

(Eds.), Binge eating: Nature, assessment, and treatment (pp. 317–360). Guilford.

Goddard

Salerno

Hibbs

Raenker

Naumann

Arcelus

Ayton

Boughton

Connan

Goss

Lacey

Laszlo

Morgan

Moore

Robertson

Schreiber-Kounine

Sharma

Whitehead

Schmidt

Treasure

(2013). Empirical examination of the interpersonal maintenance model of anorexia nervosa. International Journal of Eating Disorders, 46, 867–874. https://doi.org/10.1002/eat.22172

Hibbs

Magill

Goddard

Rhind

Raenker

Macdonald

Todd

Arcelus

Morgan

Beecham

Schmidt

Landau

Treasure

(2015). Clinical effectiveness of a skills training intervention for caregivers in improving patient and caregiver health following in-patient treatment for severe anorexia nervosa: Pragmatic randomized controlled trial. BJPsych Open, 1, 56–66. https://doi.org/10.1192/bjpo.bp.115.000273

Hilbert

Tuschen-Caffier

(2006). Eating Disorder Examination. Deutschsprachige Übersetzung. Verlag für Psychotherapie

Kocsis-Bogar

Ossege

Aigner

Wancata

Friedrich

(2023). Involvement, depressive symptoms, and their associations with problems and unmet needs in caregivers of adult eating disorder patients. Eating and Weight Disorders: Studies on Anorexia, Bulimia and Obesity, 28, 45. https://doi.org/10.1007/s40519-023-01572-1

Martín

Padierna

Loroño

Muñoz

Quintana

J. M.

(2017). Predictors of quality of life in patients with eating disorders. European Psychiatry, 45, 182–189. https://doi.org/10.1016/j.eurpsy.2017.07.001

Martín

Padierna

van Wijngaarden

Aguirre

Anton

Muñoz

Quintana

J. M.

(2015). Caregivers’ consequences of care among patients with eating disorders, depression or schizophrenia. BMC Psychiatry, 15, 124. https://doi.org/10.1186/s12888-015-0507-9

10.

Padierna

Martín

Aguirre

Gonzáles

Muñoz

Quintana

J. M.

(2013). Burden of caregiving amongst family caregivers of patients with eating disorders. Social Psychiatry and Psychiatric Epidemiology, 48, 151–161. https://doi.org/10.1007/s00127-012-0525-6

11.

Slater

Treasure

Schmidt

Gilchrist

Wade

T. D

, (2015). A pilot study of associations between treatment of anorexia nervosa and carers’ distress. Clinical Psychology & Psychotherapy, 22, 372–376. https://doi.org/10.1002/cpp.1895

12.

Stefanini

M. C.

Troiani

M. R.

Caselli

Dirindelli

Lucarelli

Caini

Martinetti

M. G.

(2019). Living with someone with an eating disorder: Factors affecting the caregivers’ burden. Eating and Weight Disorders: Studies on Anorexia, Bulimia and Obesity, 24, 1209–1214. https://doi.org/10.1007/s40519-018-0480-7

13.

Treasure

Schmidt

(2013). The cognitive-interpersonal maintenance model of anorexia nervosa revisited: A summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors. Journal of Eating Disorders, 1, 13. https://doi.org/10.1186/2050-2974-1-13

14.

Treasure

Willmott

Ambwani

Cardi

Bryan

D. C.

Rowlands

Schmidt

(2020). Cognitive interpersonal model for anorexia nervosa revisited: The perpetuating factors that contribute to the development of severe and enduring illness. Journal of Clinical Medicine, 9, 630. https://doi.org/10.3390/jcm9030630

15.

Van Wijngaarden

Schene

A. H.

Koeter

Vazquez-Barquero

J. L.

Knudsen

H. C.

Lasalvia

McCrone

. (2000). Caregiving in schizophrenia: development, internal consistency and reliability of the Involvement Evaluation Questionnaire – European version. EPSILON Study 4. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs. British Journal of Psychiatry, 39, 21–27. https://doi.org/10.1192/bjp.177.39.s21

16.

Zabala

M. J.

Macdonald

Treasure

(2009). Appraisal of caregiving burden expressed emotion and psychological distress in families of people with eating disorders: A systematic review. European Eating Disorders Review, 17, 338–349. https://doi.org/10.1002/erv.925