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Abstract

Objective

To investigate the suicide risk factors among caregivers of individuals with depression who may develop suicidal ideation due to the ongoing challenges of managing the patient's mood fluctuations.

Methods

This cross-sectional study enrolled dyads of patients with depression and their caregivers from a medical centre. The assessment included a psychiatric diagnostic interview, the Hospital Anxiety and Depression Scale, the List of Threatening Experiences, Benefit Finding Scale, Numerical Pain Rating Scale, Stigma Subscale of the Explanatory Model Interview Catalogue, Big Five Inventory-10, the Family APGAR Index and the Suicide Assessment Scale. Univariate and multivariate regression analysis were used to explore the interrelationship between the mental health of patients and caregivers.

Results

Among the 125 caregivers, 60.0% (n = 75) were females. The most common psychiatric diagnoses were depressive disorders (33 of 125; 26.4%), followed by anxiety disorders (21 of 125; 16.8%) and insomnia disorder (19 of 125; 15.2%). There was a significant association between the stressful life events of depressive patients and the suicide risk of their caregivers. The severity of anxiety and depression in caregivers was significantly associated with the suicide risk among the caregivers.

Conclusion

A relationship may exist between the psychological well-being of patients with depression and their caregivers.

Keywords

Anxiety caregivers depression stress suicide

Introduction

Depression is a severe condition associated with impaired quality of life, frequent comorbidity with illness and an increased risk of mortality.¹ Prior research has revealed a rise in depression rates within the U.S. population.² The prevalence of past-year depression in the U.S. in 2020 stood at 9.2%.³

The increasing trend in the prevalence of depression is similar to that seen in Taiwan. For example, in a study based on Taiwan's National Health Insurance programme, the prevalence of treated depressive disorders increased from 1.61% in 2007 to 1.92% in 2016; indicating a 25% increase during that period.⁴ Another study revealed healthcare accessibility of depression services stood at 83%; however, the principal impediment was the initial contact, which was only 27%.⁵ The fact that there is a pattern of infrequently seeking help underscores the importance of improving early detection for depression.⁶

Those caring for patients with illness may develop depression due to challenges for the patient's physical well-being and mood fluctuations.⁷ The prevalence of depressive symptoms among caregivers of patients with dementia and epilepsy was 24.8%⁸ and 23.3%,⁹ respectively. Mental illnesses can impose a significant burden on caregivers across various conditions, including bipolar disorder,¹⁰ dementia,^11–13 attention deficit hyperactivity disorder,^14,15 and severe mental illness.¹⁶ Family caregivers of individuals with mental illness may indeed experience stigma towards their ill family members. Additionally, the emotional burden they carry can significantly contribute to this stigma.^17–19 The occurrence of depression among caregivers of individuals with depression is more frequent than that among caregivers of individuals with other physical conditions, such as head and neck cancer and Parkinson's disease.²⁰ It is crucial to tackle this matter through treatments and by devising interventions to prevent depression in caregivers.

Depression is linked to several psychological issues, causes distress among caregivers and carries an increased risk of suicide.²¹ Studies have reported cases of suicidal thoughts and actual suicides among caregivers, including those caring of family members with dementia, schizophrenia and cancer.^22–25 Among caregivers, those experiencing thoughts of suicide had a higher percentage of probable depression.²⁶ Because of the connection between mental health status and the increased risk of suicide among caregivers, clinicians should place emphasis on the psychosocial well-being of caregivers.

To date, few studies have investigated suicide risk among caregivers of depressive individuals. A more comprehensive understanding of these intricate connections can assist mental health professionals in recognizing caregivers that are at risk and in delivering tailored interventions to support them. Therefore, the objective of this current study was to assess the occurrence of suicide and the associated factors linked to suicide in caregivers of individuals with depressive disorders.

Patients and methods

Study participants and design

This cross-sectional study enrolled consecutive patients from the psychiatric ward or psychiatric outpatient clinic at Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung between October 2021 and September 2022. The inclusion criteria were as follows: (i) individuals who were caregivers of patients with depressive disorders, defined as those residing with the patient and responsible for their well-being; (ii) individuals who were capable of comprehending the study's procedures; (iii) individuals that provided signed consent to be involved in the study. The exclusion criterion was as follows: (i) individuals without the physical strength to complete the questionnaire or undergo a clinical interview.

Ethical approval was obtained from the Human Research Ethics Committee of Chang Gung Memorial Hospital (no. 202002316B0; 18 January 2021). All study participants provided written informed consent to be involved in the study. Every effort was made to de-identify all patient details to safeguard their privacy.

Study procedure

The study procedure consisted of the following steps: (i) patients with depressive disorders and their caregivers provided written informed consent; (ii) depressive patients and their caregivers attended an appointment and were identified as able to fulfil the inclusion criteria; (iii) a senior psychiatrist (Y.L.) used the Mini-International neuropsychiatric interview (MINI) to establish a psychiatric diagnosis;²⁷ and (iv) a trained research assistant conducted in-person interviews with the patients and their caregivers to collect clinical data. These data were gathered from clinical rating scales. The reporting of this study adheres to the STROBE guidelines.²⁸

Study assessments

Hospital anxiety and depression scale

The Hospital Anxiety and Depression Scale (HADS) is a 14-item questionnaire that is designed to assess the severity of symptoms related to anxiety and depression.²⁹ It is widely utilized in hospital and primary care settings.³⁰ Seven of the 14 items are dedicated to measuring anxiety and the remaining seven items pertain to depression. Each item offers four response options, scored from 0 to 3; and the anxiety (HADS-A) and depression (HADS-D) subscales provide separate measurements.³¹

Mini-International neuropsychiatric interview

The MINI was created as a structured interview tool to aid researchers in diagnosing psychiatric disorders.²⁷ Its primary purpose is to support epidemiological studies.³² In most diagnostic sections, only one or two screening questions are initially used to exclude a diagnosis if answered negatively. When screening questions receive positive responses, further exploration of other diagnostic criteria is performed.

Suicide assessment scale

The Suicide Assessment Scale (SAS) was created through a prospective study focused on individuals with a history of repeated suicide attempts.³³ The SAS exhibits robust reliability and validity, making it a valuable tool for assessing patients' suicide risk.³⁴ The SAS is structured around four key dimensions: negative ideation, positive ideation, impulsivity and aggression. Each of these dimensions comprises five items. The total score of the SAS ranges from 0 to 80, with higher scores indicating a greater severity of suicide risk.³⁵

Big five inventory-10

The Big Five Inventory-10 (BFI-10) is an assessment tool for measuring personality traits.³⁶ It assesses five key personality traits: neuroticism, extraversion, openness, conscientiousness and agreeableness. Scores on the BFI-10 range from 0 to 10. The test-retest stability indicates good consistency over time.³⁶

Family APGAR index

The family ‘Adaptation, Partnership, Growth, Affection, Resolve’ (APGAR) index is designed to evaluate a perception of family dynamics and the support received within the family structure.³⁷ It is based on five parameters: adaptation, partnership, growth, affection and resolve. Distortions in any aspects may cause difficulties in child development, potentially causing dysfunction. The five parameters use a three-point scale ranging from 0 (rarely) to 2 (almost always). The total scores on the family APGAR index range from 0 to 10, with higher scores indicating a greater degree of family functioning.³⁸

Stigma scale of the explanatory model interview catalogue

The Explanatory Model Interview Catalogue (EMIC) is an interview measuring perceived attitudes and behaviour towards stigmatized individuals.³⁹ It is widely utilized in the field of cultural psychiatry. Its primary focus has been on understanding patients' behaviours related to illness and the stigma associated with this behaviour.⁴⁰ The total score ranges from 0 to 24, with higher scores indicating a higher level of perceived stigma.

List of threatening experiences

The List of Threatening Experiences Questionnaire (LTEQ) is a survey employed to evaluate stressful life events in epidemiological research.⁴¹ It comprises 12 yes-or-no questions and serves as a self-report tool for assessing threatening life events. It is particularly suitable for psychiatric, psychological and social studies, where other variables like social support, coping strategies and cognitive factors are of interest.⁴²

Benefit finding scale

The Benefit Finding Scale (BFS) comprises six dimensions: acceptance, family relationships, worldview, personal growth, social connections and healthy behaviour. Its scores range from 1 to 5. The total score is calculated as the sum of the item scores, resulting in a total score ranging from 22 to 110 points. A higher score signifies a stronger sense of benefit finding stemming from the experience of illness.⁴³

Numerical pain rating scale

The Numerical Pain Rating Scale (NPRS) is an 11-point scale used for individuals to self-report their pain intensity.⁴⁴ This scale allows respondents to select a whole number from 0 (no pain) to 10 (the most severe pain) to represent the level of pain intensity they are experiencing. The NPRS is divided into categories such as: no pain, mild pain, moderate pain and severe pain.⁴⁵

Statistical analyses

All statistical analyses were performed using IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY, USA). Continuous data are presented as mean ± SD or median (interquartile range) and were compared using paired t-test. Categorical data are presented as n of patients (%) and were compared using χ²-test. Demographic information and clinical features were compared between individuals who were patients with depressive disorder and their caregivers. The study examined the associations between caregivers' suicidality and the characteristics of depressive patients and caregivers using univariate regression analysis. Factors that demonstrated significant associations with caregivers' suicidality were included in a stepwise multivariate regression analysis. A P-value <0.05 was considered statistically significant.

Results

A total of 141 caregivers were initially recruited for this study, but 16 subsequently declined to participate. Data collection was completed with the remaining 125 patients, giving a response rate of 88.7%. The demographic and clinical data of the depressive patients and their caregivers are presented in Table 1. Of the 125 caregivers who completed the study, 60.0% (n = 75) were females. The mean ± SD age of the caregivers was 52.73 ± 14.97 years. Their mean ±SD duration of caregiving was 8.23 ± 7.85 years. Their mean ± SD education level was 13.10 ± 3.21 years. Eighty-four (67.2%) of the 125 caregivers were married and 47.2% (59 of 125) were currently unemployed. A total of 63 of 125 (50.4%) caregivers had a co-morbidity of physical illness; 33 of 125 (26.4%) had a self-labelling psychiatric history, six of 125 (4.8%) had a past suicide attempt history and 19 of 125 (15.2%) had a family suicide history.

Table 1.

Demographic and clinical characteristics of the depressive patients and their caregivers (n = 250) included in a study that investigated the occurrence of suicide and the associated factors linked to suicide in caregivers of individuals with depressive disorders.

Characteristic	Patients n = 125	Caregivers n = 125	Total n = 250	Paired t-test or χ²-test^a	P-value
Sex				5.88	P = 0.015
Male	32 (25.6)	50 (40.0)	82 (32.8)
Female	93 (74.4)	75 (60.0)	168 (67.2)
Age, years	55.62 ± 16.61	52.73 ± 14.97	54.18 ± 15.85	1.45	NS
Age of onset	46.21 ± 15.96
Duration of depression, years	9.34 ± 8.60
Duration of caregiving, years		8.23 ± 7.85
Duration of education, years	11.82 ± 4.08	13.10 ± 3.21	12.46 ± 3.72	−2.76	P = 0.006
Education				6.95	P = 0.008
<12 years	40 (32.0)	22 (17.6)	62 (24.8)
≥12 years	85 (68.0)	103 (82.4)	188 (75.2)
Marital status				2.46	NS
Unmarried	53 (42.4)	41 (32.8)	94 (37.6)
Married	72 (57.6)	84 (67.2)	156 (62.4)
Unemployed	94 (75.2)	59 (47.2)	153 (61.2)	20.64	P < 0.001
Comorbid with other diseases	87 (69.6)	63 (50.4)	150 (60.0)	9.60	P = 0.002
Self-labelling psychiatric history				145.57	P < 0.001
No psychiatric history	0 (0.0)	92 (73.6)	92 (36.8)
Depressive disorder	106 (84.8)	18 (14.4)	124 (49.6)
Anxiety disorder	21 (16.8)	8 (6.4)	29 (11.6)
Panic	3 (2.4)	3 (2.4)	6 (2.4)
Insomnia	54 (43.2)	13 (10.4)	67 (26.8)
Suicide attempt history	36 (28.8)	6 (4.8)	42 (16.8)	25.86	P < 0.001
Anxiolytics/hypnotics use	107 (85.6)	34 (27.2)	141 (56.4)	86.68	P < 0.001
Family psychiatric history				5.24	P = 0.022
No psychiatric history	78 (62.4)	60 (48.0)	138 (55.2)
Depressive disorder	29 (23.2)	60 (48.0)	89 (35.6)
Anxiety disorder	6 (4.8)	2 (1.6)	8 (3.2)
Dementia	5 (4.0)	0 (0.0)	5 (2.0)
Insomnia	3 (2.4)	1(0.8)	4 (1.6)
Family suicide history	7 (5.6)	19 (15.2)	26 (10.4)	6.18	P = 0.013
NPRS	3.77 (0–10)	2.46 (0–10)	3.11 (0–10)	3.40	P = 0.001
HADS	15.60 ± 8.75	10.27 ± 7.62	12.94 ± 8.61	5.13	P < 0.001
HADS-D	7.90 ± 4.82	4.80 ± 3.87	6.35 ± 4.63	5.62	P < 0.001
HADS-A	7.70 ± 4.65	5.47 ± 4.40	6.58 ± 4.66	3.88	P < 0.001
APGAR	6.86 ± 3.45	6.52 ± 3.52	6.69 ± 3.48	0.76	NS
BFI-10
Extraversion	4.89 ± 2.66	5.70 ± 2.52	5.30 ± 2.62	−2.49	P = 0.013
Agreeableness	5.53 ± 1.60	6.26 ± 1.68	5.89 ± 1.68	−3.51	P = 0.001
Conscientiousness	8.07 ± 1.83	7.78 ± 1.67	7.92 ± 1.76	1.34	NS
Neuroticism	7.26 ± 1.97	5.57 ± 1.89	6.41 ± 2.11	6.90	P < 0.001
Openness	5.34 ± 2.60	6.38 ± 2.34	5.86 ± 2.52	−3.30	P = 0.001
LTEQ	1.07 (0–6)	1.15 (0–5)	1.11 (0–6)	−0.51	NS
BFS total scores	48.51 ± 21.92	62.50 ± 20.96	55.51 ± 22.52	−5.16	P < 0.001
Acceptance	7.79 ± 4.14	9.65 ± 3.23	8.72 ± 3.82	−3.95	P < 0.001
Family relations	4.66 ± 2.85	5.89 ± 2.50	5.28 ± 2.75	−3.61	P < 0.001
World view	7.14 ± 3.92	10.27 ± 4.44	8.70 ± 4.47	−5.92	P < 0.001
Personal growth	13.51 ± 7.96	20.05 ± 7.92	16.78 ± 8.58	−6.51	P < 0.001
Social relations	7.43 ± 4.59	7.20 ± 3.81	7.32 ± 4.21	0.44	NS
Health behaviour	7.98 ± 4.48	9.45 ± 4.23	8.71 ± 4.41	−2.67	P = 0.008
MINI suicidality	2.79 (0–33)	0.79 (0–33)	1.79 (0–33)	3.15	P = 0.002
MINI suicidality level				46.67	P < 0.001
High risk	7 (5.6)	3 (2.4)	10 (4.0)
Moderate risk	7 (5.6)	2 (1.6)	9 (3.6)
Low risk	48 (38.4)	8 (6.4)	56 (22.4)
No risk	63 (50.4)	112 (89.6)	175 (70.0)
SAS total scores	20.86 (0–72)	12.50 (0–57)	16.68 (0–72)	4.81	P < 0.001
Negative ideation	4.88 (0–20)	1.97 (0–20)	3.42 (0–20)	4.82	P < 0.001
Positive ideation	9.62 (0–20)	6.31 (0–20)	7.97 (0–20)	4.08	P < 0.001
Impulsivity	2.23 (0–19)	2.06 (0–17)	2.14 (0–19)	0.46	NS
Aggression	4.13 (0–18)	2.17 (0–13)	3.15 (0–18)	3.86	P < 0.001
EMIC Stigma Scale	9.73 (0–36)	6.62 (0–36)	8.18 (0–36)	2.71	P = 0.007

Data presented as mean ± SD, median (interquartile range) or n of participants (%).

Continuous data were compared using paired t-test; and categorical data were compared using χ²-test; NS, no significant between-group difference (P ≥ 0.05).

NPRS, Numerical Pain Rating Scale; HADS, Hospital Anxiety and Depression Scale; HADS-D, Depression scale of the HADS; HADS-A, Anxiety scale of the HADS; APGAR, Family APGAR Index; BFI-10, Big Five Inventory-10; LTEQ, List of Threatening Experiences; BFS, Benefit Finding Scale; MINI, Mini International Neuropsychiatric Interview; SAS, Suicide Assessment Scale; EMIC, Explanatory Model Interview Catalogue.

A total of 66 (52.8%) caregivers had a psychiatric diagnosis (Table 2). The most common psychiatric diagnoses of the caregivers were depressive disorders (33 of 125; 26.4%), followed by anxiety disorders (21 of 125; 16.8%) and insomnia disorder (19 of 125; 15.2%). Among the depressive disorders, the most prevalent was major depressive disorder (15 of 125; 12.0%), followed by other specified depressive disorder (10 of 125; 8.0%) and persistent depressive disorder (eight of 125; 6.4%). Among the anxiety disorders, the most prevalent was other specified anxiety disorder (11 of 125; 8.8%), followed by generalized anxiety disorder (eight of 125; 6.4%), panic disorder (one of 125; 0.8%) and simple phobia (one of 125; 0.8%).

Table 2.

Psychiatric diagnoses of the depressive patients and their caregivers (n = 250) included in a study that investigated the occurrence of suicide and the associated factors linked to suicide in caregivers of individuals with depressive disorders.

MINI diagnosis	Patients n = 125	Caregivers n = 125
Depressive disorders	125 (100.0)	33 (26.4)
Other specified depressive disorder	11 (8.8)	10 (8.0)
Major depressive disorder	96 (76.8)	15 (12.0)
Persistent depressive disorder	18 (14.4)	8 (6.4)
Insomnia	0 (0.0)	19 (15.2)
Anxiety disorders	15 (12.0)	21 (16.8)
Other specified anxiety disorder	3 (2.4)	11 (8.8)
Panic disorder	9 (7.2)	1 (0.8)
Generalized anxiety disorder	1 (0.8)	8 (6.4)
Obsessive-compulsive disorder	2 (1.6)	0 (0.0)
Simple phobia	0 (0.0)	1 (0.8)
Post-traumatic stress disorder	1 (0.8)	0 (0.0)
Bipolar disorder	0 (0.0)	2 (1.6)
Borderline personality disorder	4 (3.2)	1 (0.8)
Schizophrenia	0 (0.0)	2 (1.6)
Somatoform disorder	0 (0.0)	1 (0.8)
Adjustment disorder	0 (0.0)	1 (0.8)
Attention deficit hyperactivity disorder	1 (0.8)	0 (0.0)
No diagnosis	0 (0.0)	59 (47.2)

Data presented as n of participants (%).

MINI, Mini International Neuropsychiatric Interview.

In the univariate analyses, factors significantly associated with suicide risk included higher anxiety scores (β = 0.572; 95% confidence interval [CI], 1.081, 1.823, P < 0.001), higher depressive scores (β = 0.528; 95% CI, 1.086, 1.962, P < 0.001), higher NPRS scores (β = 0.287; 95% CI, 0.469, 1.847, P = 0.001), lower APGAR scores (β = –0.308; 95% CI, –1.519, –0.440, P < 0.001), higher LTEQ scores (β = 0.351; 95% CI, 1.616, 4.555, P < 0.001), higher BFI-10-Neuroticism scores (β = 0.362; 95% CI, 1.153, 3.116, P < 0.001), higher EMIC scores (β = 0.383; 95% CI, 0.308, 0.774, P < 0.001), marriage status (β = –0.270; 95% CI, –10.473, –2.327, P = 0.002) and depressive disorder (β = 0.475; 95% CI, 8.032,15.961, P < 0.001) (Table 3). Additionally, factors that were significantly associated with suicide risk among caregivers included the depressive patients’ age (β = –0.274; 95% CI, –0.300, –0.069, P = 0.002), patients’ marriage status (β = –0.303; 95% CI, –10.653, –2.993, P = 0.001), higher NPRS scores (β = 0.196; 95% CI, 0.069, 1.251, P = 0.029), higher LTEQ scores (β = 0.321; 95% CI, 1.387, 4.467, P < 0.001) and higher BFN-10-Neuroticism scores (β = 0.195; 95% CI, 0.114, 2.098, P = 0.029).

Table 3.

Univariate analysis of predictors of the Suicide Assessment Scale (SAS) in the caregivers (n = 125) of depressive patients included in a study that investigated the occurrence of suicide and the associated factors linked to suicide in caregivers of individuals with depressive disorders.

	Univariate analysis
Variable	B	SE	$β$	P-value	95% confidence interval
Caregivers
Female	3.707	2.021	0.163	NS	−0.293, 7.706
Age	−0.082	0.067	−0.110	NS	−0.214, 0.050
Education years	−0.436	0.311	−0.126	NS	−1.052, 0.179
Duration of caring	−0.049	0.129	−0.034	NS	−0.305, 0.207
Married	−6.400	2.058	−0.270	P = 0.002	−10.473, –2.327
Anxiolytics	1.853	2.249	0.074	NS	−2.598, 6.304
NPRS	1.158	0.348	0.287	P = 0.001	0.469, 1.847
HADS-D	1.524	0.221	0.528	P < 0.001	1.086, 1.962
HADS-A	1.452	0.188	0.572	P < 0.001	1.081, 1.823
APGAR	−0.979	0.273	−0.308	P < 0.001	−1.519, –0.440
LTEQ	3.085	0.743	0.351	P < 0.001	1.616, 4.555
BFI-10-N	2.135	0.496	0.362	P < 0.001	1.153, 3.116
BFS	−0.090	0.047	−0.170	NS	−0.184, 0.003
EMIC	0.541	0.118	0.383	P < 0.001	0.308, 0.774
Depression	11.996	2.003	0.475	P < 0.001	8.032, 15.961
Patients
Female	1.853	2.293	0.073	NS	−2.685, 6.392
Age	−0.184	0.058	−0.274	P = 0.002	−0.300, –0.069
Education years	0.218	0.246	0.079	NS	−0.270, 0.705
Duration of depression	−0.113	0.118	−0.087	NS	−0.346, 0.120
Married	−6.823	1.935	−0.303	P = 0.001	−10.653, –2.993
Anxiolytics	2.860	2.846	0.090	NS	−2.773, 8.494
NPRS	0.660	0.298	0.196	P = 0.029	0.069, 1.251
HADS-D	0.268	0.208	0.116	NS	−0.143, 0.679
HADS-A	0.234	0.215	0.098	NS	−0.192, 0.661
APGAR	−0.293	0.291	−0.090	NS	−0.869, 0.283
LTEQ	2.927	0.778	0.321	P < 0.001	1.387, 4.467
BFI-10-N	1.106	0.501	0.195	P = 0.029	0.114, 2.098
BFS	−0.048	0.046	−0.095	NS	−0.139, 0.042
EMIC	0.167	0.099	0.151	NS	−0.028, 0.362

NS, no significant association (P ≥ 0.05).

NPRS, Numerical Pain Rating Scale; HADS-D; depression scale of the Hospital Anxiety and Depression Scale; HADS-A, anxiety scale of the Hospital Anxiety and Depression Scale; APGAR, Family APGAR Index; LTEQ, List of Threatening Experiences; BFI-10-N, Big Five Inventory-10-Neuroticism; BFS, Benefit Finding Scale; EMIC, Explanatory Model Interview Catalogue – Stigma Subscale.

When the above factors were analysed relative to the SAS using multivariate linear regression analysis, higher severity of anxiety (β = 0.318; 95% CI, 0.286, 1.329, P = 0.003) and higher severity of depression (β = 0.282; 95% CI, 0.244, 1.384, P = 0.005) in caregivers; and more stressful life events (β = 0.188; 95% CI, 0.358, –3.068, P = 0.014) in patients were three significant associated factors (Table 4).

Table 4.

Multivariate linear regression analysis of predictors of the Suicide Assessment Scale (SAS) in the caregivers (n = 125) of depressive patients included in a study that investigated the occurrence of suicide and the associated factors linked to suicide in caregivers of individuals with depressive disorders.

Variable	SAS
Variable	B	SE	$β$	P-value	95% confidence interval	Tolerance	Variance inflation factor	Condition index
Caregiver HADS-A	0.808	0.264	0.318	P = 0.003	0.286, 1.329	0.466	2.145	2.594
Caregiver HADS-D	0.814	0.288	0.282	P = 0.005	0.244, 1.384	0.506	1.977	3.628
Patient LTEQ	1.713	0.684	0.188	P = 0.014	0.358, –3.068	0.892	1.121	5.382

HADS-A, anxiety scale of the Hospital Anxiety and Depression Scale; HADS-D; depression scale of the Hospital Anxiety and Depression Scale; LTEQ, List of Threatening Experiences.

Discussion

To the best of our knowledge, this current study appears to be the first to focus on the associated factors of suicide risk among caregivers of individuals with depressive disorder. Caregivers taking care of patients with depression often bear the weight of responsibilities. They are at risk of developing mental health conditions. A report highlighted caregivers providing care for relatives with depression experienced lower health status and mental component scores.⁴⁶ This previous study supported the current finding that caregivers of depressive patients have a high prevalence of depression.

Caregivers' depression or anxiety could have originated either before they began caregiving for depressive individuals or as a consequence of their caregiving responsibilities. This involves the idea of pre-existing mood symptoms or depression/anxiety secondary to the caregiving burden. Caregivers could be close relatives of individuals with mood disorders, so they might share similar genetic or psychological predispositions.²⁰ Therefore, it is advisable to conduct further research aimed at providing a clearer clarification of this concept.

At present, the responsibilities of caregivers can cause an increased risk of suicidal thoughts and behaviours, especially when caring for individuals with chronic illnesses.⁴⁷ Individuals providing care for patients with a mental disorder experienced notably higher rates of suicidal thoughts.²⁶ A previous study demonstrated that 25.7% of caregivers responsible for the well-being of patients with mood disorders were at risk of suicide or reported having suicidal thoughts.⁴⁸ Recognizing factors of suicide risk is crucial in focusing on suicide prevention.

This current study identified three significant factors associated with an increased risk of suicide among the caregivers of depressive patients: (i) the severity of anxiety experienced by the caregiver; (ii) the degree of depression of the caregiver; and (iii) the occurrence of stressful life events in the depressive patient's life. Of these three risk factors, the caregivers’ severity of anxiety was the most prominent factor associated with the caregiver’s suicide risk. Caregivers providing support to individuals with psychiatric disorders may experience elevated anxiety and depression compared with caregivers of individuals with physical illnesses.^49,50 In addition, caregivers of depressive patients utilize more healthcare resources than caregivers of adults with other diseases.⁴⁶ A review found that anxiety is a statistically significant predictor of suicide ideation and attempts; however, it was not linked to an increased risk of actual suicide deaths.⁵¹ Based on these studies, it appears that caregivers experiencing high levels of anxiety may have an increased vulnerability to developing suicidal thoughts.

Severity of depression was one of the significant factors associated with an increased risk of suicide among caregivers of depressive patients in this study. Depression has been highlighted as a crucial risk factor for suicide among caregivers.⁵² There were various risk factors associated with suicidality in caregivers and depression was among the factors considered.⁵² This reaffirms the recognition of depression as an important element in addressing suicide risk among caregivers.²⁵ This concept aligns with the current findings, which indicate that depression severity is an associated factor of suicide risk among caregivers of patients with depressive disorders.

Stressful life events experienced by individuals with depression were associated with suicide risk among caregivers in the current study. This finding suggested the partner effect of a patient’s stressor existed and might impact the caregiver’s suicide risk. In a study focusing on the suicide risk of the primary caregivers of psychiatric patients, the caregiver’s probability of suicide was related to the patient’s duration of illness, presence of physical illness and compliance with treatment.⁵³ However, there is a lack of existing research providing direct evidence for a connection between caregiver suicide and the stress experienced by depressive patients. Further research could be directed toward investigating this specific issue.

In addition to the aforementioned significant risk factors, the current study examined various factors associated with caregivers, including being unmarried, having elevated neuroticism scores, reporting higher levels of pain, showing increased stigma, encountering multiple stressful life events and having poor family support. Regarding the factors related to patients, the current study observed that younger age, being unmarried, having elevated neuroticism scores and reporting higher levels of pain played possible roles. Partially corroborating these current findings, prior research has indicated that within the caregiving community, several factors could contribute to an increased risk of suicide. For example, these include assuming the primary caregiving role and experiencing a lack of support from co-caregivers.²⁶ Although these factors were determined to be non-significant after multiple linear regression analysis, attention should still be paid to them.

Two notable strengths of this current study were the high response rate and the utilization of a structured clinical interview conducted by psychiatrists. However, there were several limitations. First, the use of consecutive sampling introduced the potential for sampling bias. Nonetheless, the study achieved a substantial response rate of 88.7% among caregivers, which somewhat mitigated this limitation. Secondly, the study population was drawn from a hospital setting, potentially limiting their representativeness for the broader general population. Thirdly, this study employed a cross-sectional design, which limited the ability to examine the caregivers' suicide risk over an extended duration. Subsequent longitudinal studies to investigate suicide morbidity and the connection between the patients' history of depression and the emergence of suicide risk among their caregivers were necessary. Fourthly, the study did not collect specific reasons why the 16 caregivers declined to participate in this current study. Future research could delve deeper into this aspect. Fifthly, the sample size was limited so the current study might lack the statistical power to demonstrate significant results. Larger-scale studies of depressive patients and their caregivers should be performed in the future to overcome this limitation.

In conclusion, suicide was a notable risk among individuals providing care to patients with depression. Therefore, early assessment of caregivers' suicide risk is crucial. Once the evaluation is established, it becomes imperative to offer appropriate management to enhance the quality of life of caregivers and their well-being. Clinicians should remain vigilant and address the factors associated with suicide risk in caregivers of depressive patients to prevent these factors from escalating into a suicide attempt.

Supplemental Material

sj-pdf-1-imr-10.1177_03000605241266226 - Supplemental material for Suicide risks among caregivers of patients with depressive disorders

Supplemental material, sj-pdf-1-imr-10.1177_03000605241266226 for Suicide risks among caregivers of patients with depressive disorders by Chia-Chi Lin, Yu-Chi Huang, Yu Lee, Pao-Yen Lin, Nien-Mu Chiu, Chi-Fa Hung and Liang-Jen Wang in Journal of International Medical Research

Supplemental Material

sj-pdf-2-imr-10.1177_03000605241266226 - Supplemental material for Suicide risks among caregivers of patients with depressive disorders

Supplemental material, sj-pdf-2-imr-10.1177_03000605241266226 for Suicide risks among caregivers of patients with depressive disorders by Chia-Chi Lin, Yu-Chi Huang, Yu Lee, Pao-Yen Lin, Nien-Mu Chiu, Chi-Fa Hung and Liang-Jen Wang in Journal of International Medical Research

Footnotes

Author contributions

Chia-Chi Lin participated in interpreting data, reviewing references and drafting the manuscript. Yu Lee, Pao-Yen Lin, Yu-Chi Huang, Nien-Mu Chiu and Chi-Fa Hung participated in data collection and patient recruitment. Yu Lee and Liang-Jen Wang participated in protocol development and revised the manuscript. All authors read and approved the final manuscript and contributed to the drafting and revising of the paper.

Declaration of conflicting interest

The authors declare that there are no conflicts of interest.

Supplementary material

Supplemental material for this article is available online.

Funding

This study was supported by a grant from the Ministry of Science and Technology, Taiwan (MOST 110-2314-B-182A-041-).

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Supplementary Material

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