Schizophrenia is a severe mental disorder characterized by profound disruptions in thought processes, perceptions, emotional responsiveness, and social interactions. Patients with schizophrenia often require long-term care and support, which places significant psychological and social burdens on their caregivers. Understanding the multifaceted pressures faced by these caregivers, including family dynamics, social support, caregiving burden, internalized stigma, and depression, is crucial for developing effective interventions aimed at alleviating their stress and improving the quality of care provided to patients.

This study employed a cross-sectional design with multi-stage, stratified cluster sampling to collect data from 211 caregivers of schizophrenia patients in a multi-ethnic, less-developed region. Utilizing standardized scales such as the Family APGAR, SSRS, ZBI, ISMI, and SDS, and analyzing the data through R studio, the research provides comprehensive empirical evidence on the interrelationships among family function, social support, caregiving burden, internalized stigma, and depression. The findings reveal significant correlations among these variables, highlighting the unique challenges faced by caregivers in this demographic. This study’s robust methodology and focus on an under-researched population underscore its potential to inform targeted interventions and improve caregiver well-being.

Depression degree in caregivers of patients with schizophrenia

The results of this study showed that the depression score of family caregivers of patients with schizophrenia was (49.88 ± 11.31), which was higher than the results of the research of Pasquale et al. [19] on caregivers of patients with dementia (43.16 ± 14.36), and it may be attributed to the following reason: the complexity of the mental state of PLWS is variable, which puts the family caregivers under great psychological stress. In addition, this study found significant differences in depression scores among caregivers of different ages, educational levels, relationships with the patient, and self-care capacity (p < 0.05). The findings of Luppa et al. [20] on depression in populations indicate that older adults were more prone to depression, and the SDS scores of caregivers older than 60 years were significantly higher in this study, which may be related to the fact that older caregivers are more concerned about the prognosis of patients with schizophrenia. Research held by Demenescu et al. [21] demonstrated that education level would affect the process and regulation of emotions, and individual with poorer education level was prone to suffer from anxiety and depression. In our study, the level of depression was higher in caregivers who reported non-formal schooling. Furthermore, the relationship to patients with schizophrenia was associated with the depression level in caregivers. It was found that when the caregiver was non-relative to patients with schizophrenia, the depression level in caregivers was lower. We assumed that caregivers closer to the patient with schizophrenia looked out for patients emotionally. Therefore, it is crucial to focus on older caregivers, less educated caregivers, and caregivers who are closer to the patient and to provide them with regular psychological support to metigate the depression level.

Social support and internalized stigma as predictors of depression levels in caregivers of patients with schizophreniaSocial support

In this study, most of the caregivers had satisfactory social support with an overall social support score of 32.39 ± 8.43. A study in Ethiopian [22] showed that insufficient social support in caregivers of patients with severe psychiatric disorders was associated with depression. In addition, Jensen et al. [23] found that a higher sense of social support could reduce the level of depression in caregivers. In contrast, a lack of social support increased caregivers’ care burden, affecting caregivers’ psychological flexibility [24]. Satisfactory social support promotes and maintains an individual’s mental health and prevents the emergence and development of depression. The correlation analysis of this study indicated that social support in PLWS was associated with depression negatively (r = −0.36, p < 0.01), which was similar to the findings of Jensen et al. [23], which may be related to the fact that the more social support received by the caregivers relieves the stress of caring. It was found [25] that the perceived social support of caregivers of patients with schizophrenia had a direct impact on the level of psychological well-being of the individual. Intervention on the social support in caregivers of patients with schizophrenia could significantly improve the mental health of caregivers [26]. The results of structural equation modeling analysis in this study showed that social support could directly affect the depression level of family caregivers (β = −0.22, p < 0.05). When the caregiver felt exhausted, the other family members involved in the caregiving would have similar emotional distress [23]. As a result, the caregiver was more inclined to seek support, shifting from internal to external when social support would play a crucial role. Therefore, it is recommended to adopt policy lurches for patients with schizophrenia by increasing the reimbursement ratio of medical insurance and strengthening caregiver employment assistance to improve the practical social support system of caregivers of patients with schizophrenia and increase the sense of social support in caregivers.

Internalized stigma

In this study, the ISMI score of the caregivers was (67.61 ± 13.73). A study [27] found that caregivers of patients with schizophrenia were more likely to experience internalized stigma compared to patients with depression because the public usually believes that patients with schizophrenia are more dangerous than patients with depression, while the public’s cognitive biases lead to higher internalized stigma as caregivers of patients with schizophrenia are more prone to internalize the external misinformation [28].In all, the results of our study were generally consistent with the findings of other studies that caregivers of patients with schizophrenia dealt with a higher risk of internalized stigma. In this study, we also found that the occupation and relationship to the patient caregivers were associated with the internalized stigma. Non-farmer caregivers had lower internalized stigma scores, which may be related to their richer range of social circles and more perceived social support; meanwhile, close-relative caregivers had higher scores, which may be related to the influence of Confucianism that close-relative caregivers were more concerned about the perceptions to the patient and the family from the outside. In contrast, non-close-relative caregivers did not bear this burden. In addition, results showed that ISMI scores were significantly associated with SDS scores positively (r = 0.43, p < 0.001), and ISMI scores could positively predict SDS scores (β = 0.22, p < 0.05). Caregivers with a strong sense of internalized stigma may strongly recognize the public discrimination against them, which may feel shame and embarrassment, consequently leading to negative emotions and even withdrawal from social relations [29], and such behaviors may reduce social support necessary to care and to address difficulties in daily living. These adverse effects may lead to or exacerbate depression in caregivers. Therefore, interventions are needed to reduce caregivers’ internalized stigma and depression.

Mediation effect of social support, care burden, and internalized stigma among family function and depression in caregivers of patients with schizophrenia

The family function score (6.16 ± 3.26) in this study showed good family function. This study provides a more comprehensive understanding of the interactions between family function and depression to improve the physical and mental health and quality of life in caregivers of patients with schizophrenia. The results of the correlation analysis in this study showed that family function was negatively associated with internalized stigma, care burden, and depression and positively associated with social support (p < 0.01), which met the prerequisites for conducting the mediation effects. The results of the analysis of mediation effects in this study showed that social support, care burden, and internalized stigma had mediating effects on family function provided by caregivers of patients with schizophrenia and anxiety levels, the relative mediating effect of care burden through the internalized stigma between family functioning and anxiety levels. The relative mediating effect of social support amounted to 31.698%. Meanwhile, social support played a mediating role through internalized stigma, in which the relative mediating effect of social support through intrinsic disease shame amounted to 8.719%, and through care burden and internalized stigma amounted to 5.904%. It suggests that family function provided by caregivers indirectly affected depression levels in caregivers mainly through social support, care burden, and internalized stigma. The results of this study suggested that poor family function increased depression in caregivers, which in turn may increase the risk of poor life quality for caregivers. The mechanisms underlying the relationship between family function and caregiver depression had not been determined before this study. Family is an essential source of support for family members and a potential stressor [30]. Chronic illness in family members may disrupt the existing family order and may lead to family dysfunction [31, 32]. Poor family function in specific populations with chronic disease (e.g., stroke, Alzheimer’s disease, and dementia) has been found to affect caregiver depression in several studies [33, 34]. Our study also suggested that poor family function could affect caregiver depression. Numerous studies have demonstrated that normal family function plays a vital role in the onset and development of caregiver depression [35, 36]. Poor family function interfered with the ability to regulate emotions, distress, and unhealthy emotions in caregivers, and unhealthy emotions often caused depression in caregivers [37]; among which it was found through our study that family function influenced caregiver depression through social support, care burden, and internalized stigma. A low degree of social support can be emotionally disruptive for caregivers [24]. Social support is fundamental for caregivers in the care of patients with schizophrenia in the long term [38], and a poor sense of social support made it difficult to help themselves to regulate their unpleasant emotions, which in turn could exacerbate negative cognition and pessimism. Poor family function could also decrease social support in caregivers, and well family function played a critical role in the caregiving process.

Care burden ZBI score (26.18 ± 14.84) in this study indicated a high level of caregiver burden. Our findings are consistent to the study conducted by Sherien et al.[39], which also found that most patients with schizophrenia suffer from severe care burden. One study found [40] that family function was significantly associated with care burden. Lower levels of family function were associated with higher caregiver burden specifically. Family function was correlated with care burden negatively in our study (r = −0.40, P < 0.01). Although the causal relationship between family function and care burden could not be drawn in this study, we could hypothesize that poor family function (e.g., poor communication, hostile interactions) will exacerbate the burden perceived by caregivers. Other studies [41,42,43] have also demonstrated that dissatisfaction with family support was associated with care burden and relapses of schizophrenia.

The innovative aspect of this study lies in its focus on the caregivers of schizophrenia patients in a multi-ethnic, less-developed region, which has been underrepresented in previous research. While prior studies have explored the burden and psychological health of caregivers, they have predominantly concentrated on developed regions. For instance, a study by Liu et al. [44] examined caregiver burden in urban settings but did not account for the unique socio-cultural dynamics present in less-developed, multi-ethnic areas. Our study fills this gap by systematically analyzing the interrelationships between family function, social support, caregiving burden, internalized stigma, and depression among caregivers in such regions. The use of standardized scales like the Family APGAR, Social Support Rate Scale (SSRS), Zarit Burden Interview (ZBI), Internalized Stigma of Mental Illness (ISMI), and Self-Rating Depression Scale (SDS) provides a comprehensive and reliable dataset, which is further strengthened by advanced statistical analyses using R studio. This approach not only corroborates findings from developed regions but also uncovers unique challenges and needs specific to caregivers in less-developed, multi-ethnic settings.

The findings of this study have significant implications for clinical practice and policy-making. Understanding the intricate relationships between family function, social support, caregiving burden, internalized stigma, and depression can inform the development of targeted interventions aimed at alleviating caregiver burden and improving their psychological well-being. For example, enhancing social support networks and family function could potentially reduce caregiving burden and internalized stigma, thereby mitigating depressive symptoms among caregivers. These insights are crucial for healthcare providers and policymakers in less-developed, multi-ethnic regions, where resources are often limited, and the socio-cultural context can significantly impact the effectiveness of interventions. By addressing the specific needs of caregivers in these regions, it is possible to improve the overall quality of care for schizophrenia patients, thereby enhancing their recovery and quality of life.

Limitations and strengths

Based on the ecological system theory and attachment theory, this study adopted five scales, APGAR, SSRS, ZBI, ISMI, and SDS, to comprehensively and systematically explore the sequential mediation effects of social support, care burden, and internalized stigma among family function and depression in caregivers of patients with schizophrenia at the individual, family, and social levels. For the first time, a comprehensive and systematic measurement and evaluation of depression in caregivers of patients with schizophrenic and its influencing factors from microlevel to macrolevel was conducted in the underdeveloped multi-ethnic region of Southwest China using the epidemiological survey methodology.

In this study, the age of the study participants was large (57.2 years old on average), and 55.92% of the participants reported an education level of elementary school or below, who were unable to complete the questionnaire survey independently. For this group, a question-and-answer interview was used to conduct the survey, and despite strict quality control, measurement bias may exist. Secondly, this study was a cross-sectional study. Hence, causal relationship could not be drawn. Thirdly, this study was based on the Schizophrenia-specific cohort in the Less-developed Multi-ethnic Region of Southwestern China (SCZC-LMSWC), where monthly income of family members was generally less than 3,000 yuan. Thus, extrapolation of the results to developed regions was limited.