Perception of social support and psychotic symptoms among persons with schizophrenia: A strategy to lessen caregiver burden

Abstract

Background:

Improving patients’ perception of social support is significant not only for their re-adaptation to life but also for alleviating caregivers’ burden.

Aim:

This study aims to examine an integrated model regarding social support, psychotic symptoms and caregiver burden.

Methods:

Persons with schizophrenia (N₁ = 300) and their family caregivers (N₂ = 300) in Xinjin County, Chengdu, China, completed the survey to report their demographics, patients’ perception of social support (Duke Social Support Index), psychotic symptoms (Positive and Negative Syndrome Scale) and caregiver burden (Burden Scale for Family Caregivers, Short Version). Structural equation modelling was utilised to test the proposed model.

Results:

The degree of caregiver burden differed significantly within subgroups of patients’ gender and education, as well as caregivers’ gender, education and employment. Caregiver burden was negatively related to patients’ age and household income. Social interaction partially mediated the relationship between instrumental and subjective social support (total effect = 0.451, p < .01). Subjective social support fully mediated the impact of social interaction on psychotic symptoms (total effect = −0.099, p < .05). In the final model, instrumental social support was positively associated with social interaction (p < .001) and increased subjective social support (p < .05). Increased subjective social support showed correlation with a lower degree of psychotic symptoms (p < .01), which was related to a lower level of caregiver burden (p < .001).

Conclusion:

This study shows the associations of patients’ social support with psychotic symptoms and caregiver burden. Culture-specific psychosocial interventions should be provided for both patients and caregivers to enrich external support and reduce psychotic symptoms and caregivers’ burden within the health care environment.

Keywords

Schizophrenia psychotic symptoms social support caregiver burden

Introduction

Schizophrenia is a severe mental disorder that may be caused by various factors, such as interaction between genetic factors and environment (Beidel & Frueh, 2018). Symptom management theories suggest that symptoms occur within a context in which a patient’s symptom appraisal results from the interactions with clinicians and health care environment (Brant, Beck, & Miaskowski, 2010; Dodd et al., 2001). Patients’ symptoms may be influenced by their perception of their living environment and the people around them. Available support within the health care environment is crucial across the course of illness management. Moreover, previous research has documented the relationship of low social support to increased suicidal intention (Lyu & Zhang, 2014), poor quality of life (Hansson et al., 2002) and greater severity of psychiatric symptoms (Hamaideh, Al-Magaireh, Abu-Farsakh, & Al-Omari, 2014), which also implies that absent or inadequate social support is disadvantageous to patients’ treatment or rehabilitation. Social support refers to the resources available to an individual, which are provided by members of that individual’s social networks, such as friends, family members, acquaintances and even health care staff (Nausheen, Gidron, Peveler, & Moss-Morris, 2009; Uchino, 2006). Empirical evidence has demonstrated the connections between social support or social networks and treatment or recovery outcomes among people diagnosed with severe mental disorders (Gayer-Anderson & Morgan, 2013; Norman, Windell, Manchanda, Harricharan, & Northcott, 2012; Sibitz et al., 2011). Thus, as a crucial element of recovery-oriented services, social support mechanisms for persons with severe mental disorders have been recommended as a way to improve their re-adaptation to life in the community (Corrigan & Phelan, 2004; Kilbourne, McCarthy, Post, Welsh, & Blow, 2007).

Owing to impairments in life functioning and self-care, persons with schizophrenia (PwS) may need to depend on others to meet the demands of daily life (Beidel & Frueh, 2018). Given the heterogeneous aetiology of schizophrenia, it is necessary to have a greater understanding of the interactions between the family and the patient (Beidel & Frueh, 2018). On one hand, patients’ perceived support from their surroundings was highly associated with perception of family functioning and family environment, which was proved to predict disease relapse and re-hospitalisation for PwS (Sawant & Jethwani, 2010). Family caregivers might influence the outcome for PwS, especially in rural China (Ran et al., 2016; Ran, Xiang, Simpson, & Chan, 2005). On the other hand, the chronic, continuous and high relapsing features of schizophrenia greatly afflict not only the patients but also their families, especially when the patients relapse repeatedly and have frequent readmission to the hospital (Chan, 2011). Family caregivers were more likely to experience more burden when taking care of PwS with longer duration of illness (Adeosun, 2013; Arun, Inbakamal, Tharyan, & Premkumar, 2018; Shamsaei, Cheraghi, & Bashirian, 2015), greater severity of psychopathology or more disorganised symptoms (Kate, Grover, Kulhara, & Nehra, 2013; Papastavrou, Charalambous, Tsangari, & Karayiannis, 2010; Roick, Heider, Toumi, & Angermeyer, 2006; Shibre et al., 2003; Zhou et al., 2016) and severer degree of disability (Kumar, Suresha, Thirthalli, Arunachala, & Gangadhar, 2015; Ochoa et al., 2008). Caregiving burden remained high among family caregivers of PwS expressing lower level of social interest or interaction (Hanzawa et al., 2010) and having poorer quality of life (Hsiao & Tsai, 2014; Parabiaghi et al., 2007). It seems that improving patient’s perception of social support is not only significant for the illness but also meaningful for lessening burden of care. Unfortunately, there is scant empirical research testing the associations between perception of social support among PwS, symptom severity and burden of care.

Addressing the knowledge gaps will benefit the improvement of recovery-oriented services and psychosocial interventions targeted at families of PwS, to prevent exacerbation of the illness and alleviate the burden of care. This study aims to examine an integrated model regarding the impacts of different dimensions of social support on psychotic symptoms in schizophrenia and caregivers’ burden. In this study, we hypothesised that (1) social support might be negatively associated with psychotic symptoms in PwS and (2) psychotic symptoms might mediate the association between patients’ perception of social support and burden experienced by family caregivers in rural Chinese communities.

Methods

Participants and procedure

The study data are derived from the Chengdu Mental Health Project (CMHP) conducted in Xinjin County, Chengdu, which is a representative middle-income rural county in Southwest China (Ran et al., 2016, 2018, 2017). PwS (aged ⩾15 years) were identified through a mental health survey in 2015 in Xinjin County, Chengdu, China (Ran et al., 2019). These patients (N₁ = 300) and their respective family caregivers (i.e. parent, spouse, child, sibling, or other relative; N₂ = 300) were recruited. Trained psychiatrists with more than 5 years of clinical experience used the International Classification of Disease (ICD-10) as a standardised instrument for a diagnosis of schizophrenia to establish the diagnostic reliability of this survey (Ran et al., 2019). The field procedures and quality controls were strictly maintained by the survey team (Ran et al., 2019).

Measurements

Demographic information

The demographic information included the age, gender, education and marital status of the PwS. The marital status variable was classified into living alone (single, divorced, separated or widowed) and not alone (married or cohabiting). In addition, caregiver-related demographics were also collected, including their age, gender, education, employment, relation to the care receiver, number of family members and monthly income.

Social support

Social support was evaluated using an abbreviated version of the Duke Social Support Index (DSSI; Landerman, George, Campbell, & Blazer, 1989), a 23-item self-rated questionnaire measuring an individual’s perceived and received social support. It has three subscales: (1) a four-item Social Interaction subscale (SI; rated on a 3-point Likert-type scale: 1 = 0; 2 = 1–4; 3 = ⩾5), which measures the frequency of contact with family, friends or recourses in the community, such as ‘(Other than at work), about how often did you go to meeting of clubs, religious meetings, or other groups that you belong to in the past week?’; (2) a seven-item Subjective Social Support subscale (SSS; rated on a 3-point Likert-type scale: 1 = hardly ever, 2 = some of the time, 3 = most of the time), which measures the participants’ subjective perception of the support they receive from family and friends, such as ‘Do you know what is going on with your family and friends?’ and (3) a 12-item Instrumental Social Support subscale (ISS; dichotomous format: Yes or No), which measures the actual assistance provided by family and friends, such as ‘Do your family or friends ever help out when you are sick?’ The method of scoring for DSSI is the sum of the scores of the three subscales; a higher score indicates more social support (Koenig et al., 1993; Wardian, Robbins, Wolfersteig, Johnson, & Dustman, 2013). The instruments have been reported with an acceptable level of reliability (Rowe, Conwell, Schulberg, & Bruce, 2006). In a study using the DSSI as a measure of social support among rural Chinese population, the Cronbach’s alpha coefficient was .84 (Jia & Zhang, 2012). The internal consistency of DSSI was excellent in this study using Cronbach’s α test (α = .92).

Psychotic symptoms

Psychotic symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein, & Opler, 1987), which includes 30 items classified into three subscales: Positive, Negative and General Psychopathology. The severity of psychotic symptoms was rated from 1 (no symptoms) to 7 (the most extreme degree of symptoms). In this study, the Chinese PANSS has shown an excellent internal consistency (α = .90; Ran et al., 2015).

Caregiver burden

The Burden Scale for Family Caregivers–Short Version (BSFC-s; Graessel, Berth, Lichte, & Grau, 2014) was used to evaluate the subjective burden of the family caregivers of PwS. The 10 items are rated on a 4-point Likert-type scale, ranging from 1 (strongly disagree) to 4 (strongly agree). A higher score indicates a higher degree of subjective burden experienced by the family caregivers. In this study, the original BSFC-s was translated into Chinese, of which the internal consistency has been tested, with a value of .93 indicating an excellent reliability.

Statistical analyses

Descriptive statistics, an independent sample t-test and a Pearson correlation analysis were conducted initially. The structural equation modelling (SEM) was then utilised to examine the proposed model. In the model, caregiver burden measured by the BSFC-s was a latent variable with 10 indicators. Exploratory factor analysis (EFA) with direct oblimin rotation and confirmatory factor analysis (CFA) were combined to test the relations between caregiver burden and its indicator variables. All the items of the BSFC-s loaded on the same construct, which was in line with previous research indicating that the scores of BSFC-s adhered to a one-factor structure (Graessel et al., 2014). After specifying relations between the latent variable and its indicators, regression analyses were conducted to examine associations between the remaining variables (Sergi, Rassovsky, Nuechterlein, & Green, 2006), based on the indexes from the aforementioned bivariate correlation analysis. In our analyses, bias-corrected confidence intervals at the 95% level were employed to perform bootstrap on the basis of 5,000 bootstrap samples (Preacher & Hayes, 2008). Data analyses were conducted using SPSS statistical software (version 24.0) and AMOS (version 24.0).

Results

Demographic information and descriptive statistics

Table 1 shows the demographic information of PwS and family caregivers. Among the female caregivers, the majority of them were wives (46.9%) of the PwS. Among the male caregivers, the majority of them were fathers (43.8%) of the PwS. The average age of PwS in the child caregiver group was 64.91 years (SD: 12.14), the highest among five subgroups of kinship types. Among patients who did not have a spouse or a partner, the majority of them were taken care of by their parents (41.6%).

Table 1.

Demographic information, independent sample t-test and correlations with caregiver burden.

Variables	N (%) or M (SD) (Total N = 300)					Statistics
Variables	Parent caregiver (n = 85, 28.3%)	Spouse caregiver (n = 101, 33.7%)	Child caregiver (n = 33, 11%)	Sibling caregiver (n = 28, 9.3%)	Other relatives (n = 53, 17.7%)	Statistics
Age of patient	41.07 (10.144)	59.83 (11.491)	64.91 (12.138)	53.89 (12.997)	56.09 (18.337)	r = −.158**
Gender of patient
Female	18 (12.2%)	69 (46.9%)	23 (15.7%)	9 (6.1%)	28 (19.1%)	t = 2.648**
Male	67 (43.8%)	32 (20.9%)	10 (6.5%)	19 (12.4%)	25 (16.4%)	t = 2.648**
Education of patient
Educated	83 (33.5%)	80 (32.2%)	22 (8.9%)	23 (9.3%)	40 (16.1%)	t = −2.119*
Uneducated	2 (3.8%)	21 (40.4%)	11 (21.2%)	5 (9.6%)	13 (25.0%)	t = −2.119*
Marriage of patient
Married	28 (17.2%)	93 (57.0%)	17 (10.4%)	6 (3.7%)	19 (11.7%)	t = 0.623
Alone	57 (41.6%)	8 (5.8%)	16 (11.7%)	22 (16.1%)	34 (24.8%)	t = 0.623
Age of caregiver	66.09 (10.176)	59.06 (11.058)	45.42 (13.607)	54.71 (13.795)	54.95 (14.959)	r = .076
Gender of caregiver
Female	55 (36.4%)	33 (21.9%)	16 (10.6%)	8 (5.3%)	39 (25.8%)	t = −2.202*
Male	30 (20.1%)	68 (45.7%)	17 (11.4%)	20 (13.4%)	14 (9.4%)	t = −2.202*
Education of caregiver
Educated	61 (23.6%)	92 (35.5%)	32 (12.4%)	27 (10.4%)	47 (18.1%)	t = 2.332*
Uneducated	24 (58.6%)	9 (22.0%)	1 (2.4%)	1 (2.4%)	6 (14.6%)	t = 2.332*
Employment of caregiver
Employed	85 (28.9%)	98 (33.3%)	31 (10.6%)	28 (9.5%)	52 (17.7%)	t = −2.104*
Unemployed	0 (0.0%)	3 (50.0%)	2 (33.3%)	0 (0.0%)	1 (16.7%)	t = −2.104*
Number of family member	3.15 (1.402)	3.07 (1.251)	3.73 (1.506)	2.18 (1.249)	2.62 (1.404)	r = −.036
Household income per month (RMB)	1,794.34 (1,448.013)	1,925.49 (1,621.543)	5,799.94 (9,957.632)	1,076.07 (1,128.655)	1,784.83 (2,082.711)	r = −.178**

Note: Dependent variable: caregiver burden. Approximate RMB to US$ exchange rate, 6.2284:1.

p < .05; **p < .01; ***p < .001 (two-tailed).

The degree of burden experienced by family caregivers differed significantly depending on patients’ gender (t = 2.65, p < .01) and education (t = −2.12, p < .05), as well as caregivers’ gender (t = −2.20, p < .05), education (t = 2.33, p < .05) and employment (t = −2.10, p < .05). No significant difference in mean scores of aggressive behaviour was found within the groups of patients’ marital status. Pearson correlation analysis showed that burden of care was negatively related to patients’ age (p < .01) and household income (p < .01). The associations of caregiver burden with caregivers’ age or number of family members were found to be insignificant.

Bivariate correlations among key variables

Table 2 shows the results of bivariate correlation analysis among social support, psychotic symptoms and caregiver burden. Social interaction showed significantly positive correlation with subjective social support (p < .001). Instrumental social support was positively related to social interaction (p < .001) and subjective social support (p < .001) respectively. The associations were also found to be significant between psychotic symptoms and social interaction (p < .05), subjective social support (p < .001) or instrumental social support (p < .01). Caregiver burden was negatively associated with patients’ social interaction (p < .05). It was also positively related to patients’ psychotic symptoms (p < .001), including positive syndrome (p < .05), negative syndrome (p < .001) and general psychopathology (p < .001). The mean of the PANSS score was 58.91 (SD: 14.23), which indicated a mild severity of psychotic symptoms in average among the investigated PwS (Leucht et al., 2005).

Table 2.

Bivariate correlations among social support, psychotic symptoms and caregiver burden.

Variables	M	SD	1	2	3	4	5	6	7	8
1. DSSI_SI	3.18	0.946	1
2. DSSI_SSS	8.41	1.424	.301***	1
3. DSSI_ISS	7.72	3.323	.283***	.451***	1
4. PANSS_Total	58.91	14.229	−.122*	−.223***	−.185**	1
5. PANSS_P	13.62	4.419	−.046	−.248***	−.091	.690***	1
6. PANSS_N	15.33	5.922	−.158**	−.151**	−.239***	.799***	.211***	1
7. PANSS_GP	26.52	6.416	−.097	−.175**	−.114*	.944***	.586***	.687***	1
8. BSFC–s	27.87	5.130	−.140*	−.086	−.071	.230***	.143*	.204***	.210***	1

DSSI: Duke Social Support Index; SI: Social Interaction; SSS: Subjective Social Support; ISS: Instrumental Social Support; PANSS: Positive and Negative Syndrome Scale; P: positive; N: negative; GP: general psychopathology; BSFC-s: Burden Scale for Family Caregivers–Short Version.

p < .05; **p < .01; ***p < .001 (two-tailed).

Model test of the proposed model

EFA with direct oblimin rotation was first conducted on the BSFC-s to test the original construct validity. All the items loaded on the same construct, which was consistent with previous research indicating that the scores of BSFC-s adhered to a one-factor structure (Graessel et al., 2014). The 10 items cumulatively explained 61.32% of the total variance. Two items with communalities lower than 0.40 (BSFC-s3 and BSFC-s10) were identified and removed in the following analysis. After adjustment, the final Kaiser–Meyer–Olkin (KMO) value of the BSFC-s was 0.93 (>0.9), of which the cumulative percentage increased to 67.98% to explain the total variance.

SEM was used to test the proposed models. Model 1 was the initial model illustrating the research hypotheses, in which the single-headed arrows between variables were drawn to create correlations respectively according to the indexes from the preceding bivariate correlations analysis. In Model 1, caregiving burden was a latent variable indicated by the aforementioned eight items. According to the criteria of absolute fit indices (Hooper, Coughlan, & Mullen, 2008), the results showed that Model 1 (χ² = 148.9, df = 52, goodness of fit index (GFI) = 0.920, standardized root mean square residual (SRMR) = 0.050, root mean square error of approximation (RMSEA) = 0.079, normed fit index (NFI) = 0.923, Tucker–Lewis index (TLI) = 0.934, comparative fit index (CFI) = 0.948) failed to meet the criteria of a good model fit. Therefore, Model 1 needed to be modified. The modification indices of Model 1 suggested that the highest covariance in the default model included covariance between BSFC-s1 and BSFC-s3, as well as covariance between BSFC-s8 and BSFC-s9. Meanwhile, one item (BSFC-s4) with a factor loading lower than 0.70 were removed. Model 2 was generated after an adjustment in which χ² was decreased to 64.8 (df = 40). Figure 1 demonstrated covariance structure analysis of the final SEM. The final indices of Model 2 (GFI = 0.963, SRMR = 0.046, RMSEA = 0.046, NFI = 0.962, TLI = 0.979, CFI = 0.985) reached a good model fit for the present data.

Figure 1.

Covariance structure analysis of the final SEM.

Table 3 summarises the coefficients of each pathway in the model. First, it was found that social interaction partially mediated the relationship between instrumental social support and subjective social support, of which the total effect size was 0.451 (p < .01; 95% confidence interval (CI) [0.328, 0.550]). Second, it showed that subjective social support fully mediated the association between social interaction and psychotic symptoms among the PwS, of which the total effect size was −0.099 (p < .05; 95% CI [−0.204, −0.001]). The original direct effect of social interaction on psychotic symptoms was significant (β = −.122, p < .05), but after the subjective social support variable was entered into the model, the aforementioned direct effect turned to be insignificant (β = −.06, p > .05). As shown in the model, instrumental social support was positively associated with social interaction (β = .283, p < .001) and subjective social support (β = .188, p < .05). Increased subjective social support showed significant association with a lower degree of severity in psychotic symptoms (β = −.205, p < .01), which was related to a lower level of caregivers’ burden (β = .236, p < .001).

Table 3.

Standardised coefficients of total effect, direct effect and indirect effect in the final SEM.

Mediators	Pathways	Regression coefficients		Standardised coefficients of the SEM
Mediators	Pathways	β	95% CI	Direct effect	Indirect effect	Total effect	95% CI
SI	ISS→SI	.283***	[0.049, 0.112]	.283***		.283***	[0.163, 0.391]
	SI→SSS	.301***	[0.289, 0.616]	.188*		.188*	[0.046, 0.319]
	ISS→SSS	.451***	[0.150, 0.237]	.398**	.053**	.451**	[0.328, 0.550]
SSS	SI→SSS	.301***	[0.289, 0.616]	.188*		.188*	[0.046, 0.319]
	SSS→Psychotic symptoms	−.223***	[−3.343, −1.121]	−.205**		−.205**	[−0.323, −0.090]
	SI→Psychotic symptoms	−.122*	[−3.539, −0.135]	−.060	−.039**	−.099*	[−0.204, −0.001]
	Psychotic symptoms→Caregiver burden	.233***	[0.034, 0.096]	.236***		.236***	[0.135, 0.340]

CI: confidence interval; DSSI: Duke Social Support Index; ISS: instrumental social support; SSS: subjective social support; SI: social interaction.

p < .05; **p < .01; ***p < .001.

Discussion

To the best of our knowledge, this is the first study to evaluate the associations between social support of PwS, psychotic symptoms and caregiver burden in rural Chinese communities. This study sheds light on the model of the relationships between subjective social support, social interaction, instrumental social support, psychotic symptoms and caregiver burden.

Among sociodemographic variables, the results of this study showed that mean scores of caregiver burden were higher among family caregivers of male patients than those of female patients, which is congruent with previous studies (Jagannathan, Thirthalli, Hamza, Nagendra, & Gangadhar, 2014; Kumar et al., 2015). The possible reason may be that male patients have more severe psychotic symptoms including aggressive behaviours than female patients (Ran et al., 2015). In the social context of rural China, women, including wives or mothers, are usually expected to take charge of most household tasks. Female caregivers were also found to experience a higher degree of burden than male caregivers in this study, in accordance with prior research conducted in rural Chinese communities (Yu et al., 2017). It was also found that uneducated caregivers tended to experience heavier burdens than their counterparts. It is difficult for caregivers who have never received any education to find a high-income job, which may increase their financial stress. It is also possible that caregivers with less education tend to have limited knowledge about the illness and to be lacking in resources; hence, they were more likely to experience a greater degree of burden. The results of this study showed that family caregivers who had a job or worked as farmers tended to experience a higher burden than unemployed caregivers. One possible explanation may be the distinct difficulties in terms of work–life balance among caregivers who needed to work.

In addition, most families with PwS in rural China are poor (Ran et al., 2019). Lower income was significantly correlated to more perceived burden. This may be related to the financial stress regarding the cost of education and medication for the patients. Consistent with prior studies (Hsiao & Tsai, 2014; Igberase, Morakinyo, Lawani, James, & Omoaregba, 2012; Li, Lambert, & Lambert, 2007), we found that younger age of PwS was associated with a higher degree of caregiver burden. This may be explained by the fact that younger PwS were more likely to commit acts of aggression or violence (Biancosino et al., 2009; Caqueo-Urízar, Fond, Urzúa, Boyer, & Williams, 2016; Carr et al., 2008) or have secondary problems generated by risky actions such as substance abuse (Barlow, Grenyer, Ilkiw, & Lavalle, 2000).

Interestingly, the results of this study showed that social interaction partially mediated the relationship between instrumental social support and subjective social support, which revealed that instrumental social support tended to increase patients’ interaction with others, and more social interaction was a contributing part of their higher levels of subjective social support. This indicates that patients’ interaction with other members of their social networks may act as a possible mechanism behind the relation between received and perceived support. In addition, our findings confirmed that subjective social support fully mediated the relationship between social interaction and psychotic symptoms among PwS. Specifically, more social interaction was significantly linked to higher levels of subjective social support and lower degrees of psychotic symptoms, which is, to some extent, consistent with other studies implying the positive impacts of social networks and social contact on the recovery of people diagnosed with severe mental disorders (Corrigan & Phelan, 2004; Sibitz et al., 2011). This may be explained by the symptom management theory, which suggests that patients’ experience of symptoms may be influenced by their perception of the surroundings, including their living environment and the people around them (Dodd et al., 2001). Considering that in patients with chronic disorders, self-perception of their current conditions is crucial to their function; adverse outcomes emerge when they are not willing to struggle with disease-related problems or negative self-perceptions (Holman & Lorig, 2004). Our findings suggest that a patient’s interaction with their surroundings may influence their perception of support gained from the external world and further impact the status of the illness. Therefore, given that improvement in clinical status of PwS may be associated with changes in relatives’ attitudes, changes in caregivers’ behaviour and attitudes will be the topic of future family intervention (Giron et al., 2010).

Despite the associations between social support and psychotic symptoms, our findings also implied that a higher severity of psychotic symptoms was significantly associated with a higher degree of caregiver burden, which is in accordance with a substantial body of literature documenting the adverse influences of schizophrenia on caregiving stress (Jagannathan et al., 2014; Kumar et al., 2015; Ochoa et al., 2008; Zhou et al., 2016). This may be explained by the fact that schizophrenia could affect the patient, his or her caregivers and the whole family in various aspects. For instance, impaired functioning will not only increase expenditure on medication (Kumar et al., 2015; Suro & Weisman de Mamani, 2013) but also decrease productivity of the family (Yu et al., 2017), which leads to a heavier burden in the financial domain. More specifically, it was found that with an increase in positive or negative symptoms, caregivers’ perceived burden increased. Our findings are akin to that reported in other studies which have evaluated the mutual effects of PANSS positive and negative items on caregiver burden (Rabinowitz, Berardo, Bugarski-Kirola, & Marder, 2013; Roick et al., 2006). However, it has been controversial in terms of the relationships between caregiver burden and specific symptoms of schizophrenia (Kate et al., 2013). Some studies have reported that family caregivers suffered from a heavier burden while coping with positive symptoms (Grandón, Jenaro, & Lemos, 2008; Kate et al., 2013), which may be due to the psychological impacts of more symptomatic behaviours on the caregivers, such as violent behaviours (Hanzawa et al., 2013; Lowyck et al., 2004). In contrast, other studies have found that family caregivers perceived more burden when being confronted with the patients’ negative symptoms (Hjärthag, Helldin, Karilampi, & Norlander, 2010; Kumar et al., 2015), which may due to the possibilities that patients have more care needs at home among those with decline of social interests and avoidance to contact with non-family members (Hanzawa et al., 2010). This may accordingly increase caregivers’ workload and contribute to more burden of care. The chronic burden of providing care to PwS is likely to generate negative emotions among the caregivers (Nirmala, Vranda, & Reddy, 2011), which might be disadvantageous to the treatment or rehabilitation care of the patients.

There are several limitations in this study. First, although linkage among patients’ perception of social support, psychotic symptoms and caregiver burden was found, the specific mechanism in this pathway was still unclear. This warrants further investigation. Second, a single caregiver-related variable and the cross-sectional design failed to indicate any causal relationship between family caregiving and schizophrenia management. More longitudinal studies are warranted to examine how family caregivers specifically exert impact on social support and illness status of the PwS across the chronic course of home-based care. Finally, given the current rural sample, our findings regarding associations between perception of social support, symptom severity and caregiver burden are limited in terms of being generalised to other populations. Future studies incorporating random samplings from both rural and urban populations may help to create a comprehensive picture of interactions between family caregivers and PwS.

Despite the limitations, this study helps to understand the knowledge gaps about the mutual impacts between PwS and their family caregivers by proposing a new conceptual framework regarding the associations of social support with psychotic symptoms and caregiver burden. Our findings also have the following implications for improving recovery of schizophrenia. On the one hand, community mental health services for families with PwS would benefit from being sensitive to particular sociodemographic factors, such as age, gender, education, employment, and household income. On the other hand, our findings contribute to empirical evidence in terms of the associations between patients’ perception of social support, symptom severity and burden of care. For the caregivers, the quality of mental health care might be improved through making them and other family members acquainted with these associations. For the PwS, although their status in the pathological domain (such as severity of psychiatric symptoms) may not change, their distress associated with the environmental domain could be altered by some intervention strategies, especially perceived support from their family members (Smith & Liehr, 2018). Recovery-oriented services are thus advised to aim at strengthening emotional and instrumental social support for the PwS (Kilbourne et al., 2007). Enriching external support within the health care environment is of momentous significance to providing better care to PwS and alleviating caregiver burden. Therefore, we suggest that recovery-oriented programmes and culture-specific psychosocial interventions should include both PwS and their family caregivers (Ran et al., 2003). Ongoing expert consultation and regular monitoring training for home-based symptom management should be tailored locally to serve the needs of families who experience a high level of caregiving burden, to prevent exacerbation of schizophrenia and lessen their stress.

Conclusion

In this study, we found that social interaction partially mediates the impact of instrumental social support on subjective social support, and subjective social support fully mediates the impact of social interaction on psychotic symptoms. In the final model, instrumental social support was positively associated with social interaction, and then increased subjective social support. Increased subjective social support showed significant correlation with a lower degree of psychotic symptoms, which was related to a lower level of caregiver burden. Besides being sensitive to particular sociodemographic factors related to a higher degree of caregiver burden, these findings also imply significant interaction between family caregiving and management in schizophrenia. Future studies are warranted to clarify the mechanism of how specifically a family caregiver exerts impact on perception of social support among PwS in the chronic course of home-based care, which is crucial to preventing exacerbation of schizophrenia and alleviating caregiver burden.

Footnotes

Acknowledgements

The authors would like to express great gratitude to all the collaborative institutes (e.g. Xinjin Second People’s Hospital, Chengdu Mental Health Center, Sichuan Veterans Hospital, Jingzhou Mental Health Center, Guangyuan Mental Health Center, Santai Mental Health Center, Southwest Medical University, Sichuan College of Traditional Chinese Medicine, Chongqing Medical University, Chengdu Mental Hospital, Panzhihua Mental Health Center) and the Chengdu Mental Health Project (CMHP) Study group for collaboration, support and data collection.

Author contributions

M.-S.R. designed and directed the study. M.-M.P. formulated the research question, conducted data analysis, wrote the first draft and revised this paper. Other authors made contribution to data collection or paper revision. The final version of this paper has been approved by all authors.

Ethical standards

This investigation was approved by the University Committee on Human Research Subjects (CHRS). Written informed consent was collected from all respondents at each stage of the survey.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This survey was funded in part by Seed Funding Program for Basic Research (University of Hong Kong, 2014-2016, PI: MSR), Seed Funding Program for Applied Research (University of Hong Kong, 2014-2016, PI: MSR), Strategic Research Theme: Contemporary China Seed Funding(University of Hong Kong, 2014–2016, PI: MSR), and Mental Health Research in Chengdu, China (Department of Matching Fund, 2015-2017, PI: MSR).

ORCID iD

Mao-Sheng Ran

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