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A Systematic Review of Family Caregivers of Persons with Serious Mental Illnesses in Non-Western Countries

Family caregivers of individuals with serious mental illness (SMI) play an essential role in managing patient conditions. The shift towards community care for patients has resulted in transferring patient care to family members, resulting in significant challenges. Studies have documented the experiences of family caregivers in Western countries. However, a clear overview of family caregiver experiences of persons with SMI in non-Western countries is warranted. The purpose of this study was to integrate and summarize the current literature about family caregiver experiences in non-Western countries. Five databases were searched using relevant keywords for studies published in English from 2015 to 2020. The studies included in the review were qualitative and quantitative designs, representing several non-Western countries. This systematic review included 25 articles and data synthesized based on similarities and different findings. The findings of this systematic review will provide more knowledge on the experiences of family caregivers of persons with SMI in nonWestern countries, including burden, coping, psychological well-being, and stigma. This review found that additional research is necessary to understand the family caregiver experience and how healthcare teams can support caregivers. Further, the findings may help to inform health care policymakers to tailor strategies that support family caregivers.


INTRODUCTION
Serious mental illness (SMI) refers to longterm, persistent psychiatric disorders, specifically schizophrenia, bipolar disorder and major affective disorders [1]. The World Health Organization's (WHO) Mental Health Gap Action Programme (mhGAP) identifies, bipolar disorder, depression, schizophrenia, and other psychotic disorders as priority mental illnesses that need integrated management and interventions in low-and middle-income countries [2]. Mental illnesses are prevalent in low-and middleincome countries [3]. In several South Asian countries, the prevalence of depression and bipolar disorder was 28.4% and 0.6%, respectively [3]. In Africa, WHO estimated the mean prevalence rates by disorder are 0.28%, 0.37%, and 2.18% for schizophrenia, bipolar, and depression, respectively [4]. The estimated percentage worldwide of persons with SMIs is 22.1% [5]. Between 2011 and 2030, the projected economic cost associated with mental disorders is US $16.3 trillion worldwide [6]. The recent estimates the global burden of mental illness is 32.4% and is ranked as the fifth leading cause of disability [7].

Family Caregivers
Due to deinstitutionalization in low-and middle-income countries, family members provide the highest percentage of care for persons with mental illnesses or chronic illnesses [8]. Family caregivers take care of their relative's mental state and treatment, provide emotional support, accompany them to the hospital, and help them manage their finances [9]. Families also play an important role in providing daily routine care, supervising medication, and managing patient behavior disturbances [10]. In many non-Western societies, the reliance on family caregivers is not only because of the closer family relationships, but also, due to the lack of rehabilitation professionals in developing countries, to provide family support services [11][12][13]. In developing countries, there is a lack of infrastructure and political and financial support for mental health services in the healthcare system, such as a comprehensive family caregiver's plan in the clinical setting and in the community [12,14,15].
The effects of SMI symptoms can decrease patient functionality in various ways, including inability to complete and maintain work, interruption of There are two classifications of burden: objective and subjective. Objective burden refers to -the practical problems, difficulties and concrete and observable negative effects the illness has on family life resulting in significant life changes,‖ whereas subjective burden is -the extent to which caregivers actually feel burdened because of the situation, resulting in psychological reactions and affecting well-being‖ [20]. Burden has been researched and is better understood than in the past; however, in some non-Western countries, the experience of caregiving burdens goes undocumented [21].

Quality of Life
The manifestation of psychological illness can have an effect on the quality of life of familial caregivers, affecting such areas as health, social and economic condition, psychological well-being, and family dynamics. Eventually, this can lead to poor care and the caregivers' non-adherence to the treatment plan, issues that can worsen a patient's health. Accordingly, the accumulated caregiving demand on caregivers without adequate support can lead to the caregiver becoming a hidden patients or to increased hospital readmission rates. Caregivers of persons with SMI need help to cope with their challenges. Caregivers develop different types of coping skills, and a passive coping style may adversely affect caregiving functions [22]. It is important to provide family caregivers with assistance to meet their various needs.

Project Goal and Objectives
A qualitative systematic review was conducted to explore family caring experience for persons with schizophrenia [23]. This review highlighted three themes: -(a) caregivers emotional response toward their caregiving role, their relative diagnosed with schizophrenia, and relationship with health care professions, (b) the impacts of schizophrenia and caregiving role on their health, (c) needs among both caregivers and patients‖ [23]. This systematic review included studies across diverse countries related to specific caregivers of individuals diagnosed with schizophrenia. An example of Western countries included in the articles were the United States, Canada, Germany, and Australia; and in non-Western countries, four areas in Africa and Asia.
The current review expanded the previous review by extending the inclusion criteria to include schizophrenia, bipolar and depression disorders, and a broader range of study designs to incorporate the findings from these studies. Further, the current review included non-Western studies only. There is a need to merge these findings to understand the complexity of caregiving beyond looking at one specific channel of information, which may lack contextual relevance. Conducting a systematic review is important to understand how the experiences of caregivers are an essential component of both the caregiver's and the patient's overall health. Therefore, this systematic review aimed to explore and summarize family caregiver experiences when providing care for their relatives with severe mental illness in non-Western countries.

METHODS
The researcher followed guidance on systematic reviews published by the Centre for Reviews and Dissemination (CRD) [24]. The CRD's review protocol developed the following methods to plan systematic reviews: formulating the review question, inclusion and exclusion criteria, searching, study selection, data extraction, quality assessment, and data synthesis [24].

The Review Questions
The following review questions were framed in terms of the population, intervention, comparator and outcomes (PICOS): 1. What are the family caregiver experiences of persons with serious mental illness in non-Western countries? 2. What are the factors associated with caregiver experiences of non-Western family caregivers of patients with SMI?

Inclusion and Exclusion Criteria for Review
The review's inclusion and exclusion criteria included the following: Inclusion criteria: (a) studies focused on family caregivers who have experienced caring for persons with clinically-diagnosed SMI (schizophrenia, bipolar disorder, and major depression disorder), (b) studies published in theses, dissertations, and reports, (c) studies published between 2015 to 2020, (d) studies reported in English; (e) studies that explored qualitative and quantitative data, (f) studies that were full-text accessible, and (g) studies reported in non-Western countries.
Exclusion criteria: (a) abstracts, secondary analysis studies, and systematic reviews; (b) studies focused on other caregivers and family caregivers of an adult with any other illness, including substance-induced psychosis, dementia, or Alzheimer's disease; (c) studies reported in Western countries; (d) unpublished or grey literature, books, and conference summaries; (e) studies where participants were not caregivers for family members only; (e) studies focused on caregivers of persons with SMI in inpatient facilities; and (f) studies focused on non-family caregivers such as nurses and mental health professionals.

Search Methods
The search for this review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline [25]. The search process included: (a) selecting the databases and key terms for the search, (b) guiding in an initial search using the key terms selected, (c) removing duplicates using a filter system of the university library databases, and (d) performing an initial screening of the articles searched based on abstracts and titles.
The PRISMA flow diagram (Figure-1) for the systematic review was used to illustrate the process of review and deselection of journal articles [25]. Using advanced search techniques of the library database, the number of selecting articles with full text was 4,900 written in English between 2015 and 2020. Abstracts were assessed for eligibility and whether they addressed the inclusion criteria and topic of review. A total of 4,620 were excluded. Further, some duplicate articles were identified and excluded. A final review of abstracts and titles based on the inclusion and exclusion criteria left 74 articles, resulting in the evaluation of 25 articles for the systematic review. Of the 49 articles excluded, 25 studies not related to family caregivers only and 20 studies collected data from inpatient settings were excluded. Two studies were not related to the SMIs disorder such as intellectual disabilities and autism or not specify the types of mental illness.

Data Extraction
Quantitative data were extracted from the articles and included: publication year, country of study, setting, purpose, design, patient's diagnosis, data collection measures, and outcomes (Table-1). For qualitative data, the researcher extracted themes for each article (Table-2).

Assessing Quality of Studies
The researcher appraised the 25 studies using the Joanna Briggs Institute's critical appraisal tools [26]. The JBI has various critical appraisal tools that fit different research designs to assess the methodological quality of studies. Two appraisal tools were used to appraise the quality of studies (qualitative research and cross-sectional studies) included in this review (Table-3). Care burden and social support were directly related to depression, while social support had a direct association with care burden. For the socio-demographic variables, gender, education level, and annual income had significant associations with depression. Social support is negatively associated with care burden and depression. Care burden was correlated with depression.

Author
Topic Sample Size/ Diagnosis

Design Measures Results
Yu et al.,  Qualitative study with audio-recoded interviews, using the general inductive approach for analysis.

N=15
Type of SMI: schizophrenia Setting: India Explanatory models of mental illness expressed emotion (EE), caregiving experience, and ways of caregiver involvement and coping.
Understood caregiving burden and its related factors.
A qualitative research method with semistructured interviews using Graneheim and Lundman method for data analysis.
N=12 family caregivers Type of SMI: schizophrenia Setting: Iran The perceived objective burden as theme included two main categories: (1) heavy involvement of caregivers and (2) challenges of the healthcare system, which include neglected educational needs of caregivers, ineffective medical and health care services and limited access to services.

Characteristics of Included Studies
In the final review, 25 studies were included, which were conducted in 11 different countries and had more than one study: Iran (n = 4), Turkey (n = 4), China (n = 5), Singapore (n = 2), Jordan (n = 2), Saudi Arabia (n = 1), Ghana (n = 1), India (n = 3), Thailand (n = 1), Taiwan (n = 1), and Egypt (n = 1). Of the included studies, 18 were quantitative and seven were qualitative. The majority of quantitative studies used a cross-sectional descriptive design, while qualitative studies used a descriptive design. The majority of studies included family caregivers of individuals with more than one type of SMI: schizophrenia (n = 23), bipolar (n = 9), and depression (n = 4). The number of participants in the 25 studies varied from 12 to 459 participants. The majority of family caregivers were female, between the ages of 17 and 90. Most of the family caregivers were parents, followed by spouses, siblings (brother and sister), and children (sons and daughters). All studies collected data from outpatient and community settings.

Instruments Used in Included Studies
Table-4 lists all measurement tools used to measure the following concepts: caregiver burden, caregiver coping strategies, stigma, family function, patient function, caregiver emotional well-being, caregiver stress, and social support. The majority of studies utilized a 4 to 5-point Likert scale response format. All study instruments were translated and reported based on the participant language and the reliability and validity of all scales.
The Involvement Evaluation Questionnaire (IEQ-EU) The consequences of psychiatric disorders for relatives of people with mental illness. Ten quantitative studies measured caregiver burden using six varied tools. The most frequently used instruments were the Zarit Burden Interview (ZBI) in four studies [27][28][29][30]; the Burden Assessment Schedule Scale (BASS) in two studies [31,32]; the Caregiver Burden Inventory (CBI) in three studies [10,33,34]; and the Family Burden Interview Schedule (FBIS) in three studies [30,[35][36]. The Family Burden Scale [37] and the Perceived Family Burden Scale (PFBS) [38] were also used.
Emotional distress concepts were measured by researchers using different tools to assess the severity of depression, anxiety, and anger levels among family caregivers. The Patient Health Questionnaire (PHQ-9) was used to assess depression among family caregivers in three studies [10,30,35]. In other studies, the researchers used different tools to measure depression, such as The Taiwanese Depression Questionnaire [39] and the Chinese version of the ten-item Center for Epidemiologic Studies Depression Scale [29] were also used. Anxiety was measured by the Generalized Anxiety Disorder Scale (GAD-7) in two studies [30,35], and by the Beck Anxiety Inventory in two studies [38][39]. Two studies used tools that measure depression, anxiety, and various emotional distress: The 21-item Depression, Anxiety, Stress Scale (DASS) [27], and the Chinese version of the Symptom Checklist-90-R [36]. The Trait Anger and Anger Expression scale measures the level of anger and was used in one study [33].
The concept of coping was measured by researchers in three studies [31,32,36] using three different scales: the Arabic version of the Brief COPE Inventory, the Brief Cope scale (BCS) and the Chinese version of the Simplified Coping Style Questionnaire (SCSQ). Similarly, two studies measured stigma by the Affiliate Stigma Scale [39], and the Family Stigma Scale (FSS) [40]. Also, social support was measured by two different tools: the Multidimensional Scale of Perceived Social Support [37] and the Chinese version of the Social Support Rating Scale (SSRS) [29]. Family and patient functions, caregiver personality traits, caregiver's psychological well-being, quality of life, and the consequences of caring and self-esteem were measured with various tools.

Factors Associated with the Caregiving Experience of Non-Western Family Caregivers
In quantitative studies, the factors related to the caregiving experiences of non-Western family caregivers of patients with SMIs included (a) caregiver burden, (b) caregiver coping strategies, (c) caregiver affiliated stigma, and (d) psychological wellbeing. These factors were reported as significantly correlated (p < .05), as presented in Table 5.

Caregiver Burden
Five studies reported a high to moderate level of burden among family caregivers (28-29, 31-32, 37]. A significant factor influencing caregiver burden was caregivers who were more than 55 years old [28,37,39]. Greater caregiver burden levels were associated with being female caregivers [28,32], while one study reported that perceived family burden was at higher levels in males than females [38]. The caregiver's employment status was also associated with caregiver burden [32,37]. Further, the lower level of family caregiver education and employment status significantly impacted their financial burden [10,32,37,38,41]. High levels of caregiver burden were associated with being a parent of the patient [21, 30,36,37,39] or a spouse [32] or by being a child [28].  Studies showed that the type of SMI, such as schizophrenia [28,38,39], patient's functions [21,27,32,35], and the long duration of caregiving [21, 28,32,33,37,38] had an effect on caregiver burden. All studies concluded that high burdens were associated with providing care for male patients. However, one study found that caregiving for a female patient was related to a higher burden [21]. Furthermore, studies showed that family caregivers had a high level of developmental, physical, social, and emotional burden [32][33][34]39]. Emotional expression, coping, and a caregiver's personality dysfunctions were significant predictors of caregiver burden [31]. Simultaneously, the caregiver's personality traits (neuroticism personality traits), family functioning, and coping style affected the caregiver burden [36]. A negative association among social support, psychological well-being, and family burden was also found [29,37]. Furthermore, the burden had a significant negative relationship with coping [31]. Further, social support directly associated with care burden [29].

Caregiver Coping Strategies
One study concluded that there was no significant relationship between the caregiver or patient characteristics and coping strategies of the caregiver [42]. However, high levels of caregiver anger were related to the duration of caregiving because a lack of social support effective and coping methods, or inability to adapt to the illness [33]. The findings of two studies revealed that the coping style of family caregivers, such as avoidance strategy, were a predictor of, and directly affected, caregiver burden [31,36]. Two studies indicated that family caregivers used adaptive coping strategies [32,42]. The most frequently used coping strategies were reported in one study: acceptance, religion, active coping, planning, positive reframing practices, escaping, and emotional support; while denial, self-blame, behavioral disengagement, humor, substance use were the least used coping styles [32]. Further, one study indicated that the most caregivers were used planful problem solving and seeking social support to take care of a patient's aggressive behavior [42]. However, most family caregivers did not use efficient coping strategies, and those that were used were not used appropriately [31,36,42].

Caregiver-affiliated stigma
Caregiver-affiliated stigma is defined as internalized stigma faced by family members who are closely related to stigmatized individuals with mental illness; this stigma is a result of the public's negative view of mental illness [39,40]. Two studies focused on family caregiver-affiliated stigma [39,40]. Caregivers above the age of 30 were found to be at risk of feeling stigmatized; meaning they scored high on stigma tools [39]. In contrast, one study described that primary caregivers who were 35 years or younger felt more stigmatized than caregivers aged more than 50 years [40]. However, a high level of education was reported as a protective factor for coping with stigma [39]. Being a parent of a person with SMI had a significant highly affiliated stigma [39,40]. No relationship was found between stigma and duration of mental illness [40]. However, the two factors that decreased the level of affiliated stigma were psychiatric hospitalization and suicide attempts by the persons with SMI [39]. The affiliated stigma of caregivers is correlated with a family caregiver's self-esteem and caregiver burden, and is higher in the families of patients with schizophrenia when compared to bipolar and major depression disorders [39]. Additionally, it was reported that all four determinants of a caregiver's quality of life, physical and psychological health, social relationships and environment were significantly associated with affiliated stigma [40].

Psychological Well-Being
Female caregivers were more likely to have depression or anxiety and low psychological well-being [29,35,37,41]. However, male caregivers were associated with high levels of anger [33]. Furthermore, anger level and low psychological well-being were higher in, and more significantly associated with, single caregivers and long durations of care [33,37]. Also, high levels of stress were negatively associated with the duration of illness [41]. The level of education and annual income of the family had significant associations with depression and low psychological well-being [29,37]. Parent caregivers have higher levels of depression and anxiety than spouse caregivers [30]. However, a statistically significant relationship between the caregiver's low psychological well-being and being a spouse of patients was also reported [37]. Caregivers of persons with schizophrenia had higher levels of anxiety and stress than caregivers of patients with bipolar disorders and depression disorders [38,41]. Conversely, no significant differences were found in depression and anxiety among family caregivers of various patient diagnoses (schizophrenia, bipolar, and major depression disorder) [39]. Caregiving for male patients and poor medication adherence were associated with family caregiver anxiety, depression, and heightened level of stress [27,35]. Further, one study compared two types of caregivers (spouses and parents) who engaged in similar caregiving activities and concluded that no significant difference in a positive caregiving effect between them [30].
One study reported on caregiving reaction in four domains: -impact on schedule and health, impact on finance, lack of family support and caregiver esteem‖ and found that they were significantly associated with distress scores [16]. Social support had a negative relationship with care burden and depression [10,29]. The caregiving burden and social support were predictors of depression and had an impact on stress level [10,29]. A positive significant association was found between psychological well-being and social support [37]. Further, burden was significantly higher among caregivers who were not receiving any kind of professional support [21].

Qualitative Synthesis Results
All articles included in the current review used a phenomenological qualitative approach. Furthermore, content analysis was the most used analysis approach in the studies. The findings of seven qualitative studies were analyzed and categorized based on similarity and differences of meaning. Two main themes emerged: the impact of caregiving on families and coping strategies adopted by caregivers (Table 6 and 7).

Impact of Caregiving on Families
The impact of caregiving on the caregivers is individualized and varies, depending on the diverse family and contextual characteristics [43]. This theme synthesizes the experiences of the family caregiver for persons with SMI based on two subthemes: the negative and positive aspects of caregiving experiences. The negative aspect of the caregiving experience theme synthesized the emotional and complicated experiences reported by family caregivers in all studies. The positive aspect of the caregiving experiences theme synthesized the positive aspects related to their role and their feelings about caring.
Involving in or carrying out their regular work. Avoidance.

Negative Aspect of the Caregiving Experience
Family caregivers experience negative impacts from caregiving, including emotional stress, financial issues, a lack of community resources, and worry due to a lack of knowledge. Four authors reported the lack of availability and access to mental health care resources for caregivers and patients [11][12][13]44]. However, one study addressed the negative and positive family caregiver experience with available peer support services [45]. Furthermore, the lack of professional support for family caregivers was illustrated in six studies [11][12][13][44][45][46]. Family caregivers assumed caring without sufficient knowledge about a patient's medication or the disorder, yet had to provide care for the patient at home, managing the patient's high-risk behavior and the patient's resistance to treatment due to a lack of communication and ignorance from psychiatric healthcare providers [11][12][13][44][45][46]. However, one study addressed how peer support services impacted family experience, such as instilling hope for patient recovery, having a positive impact on caregiver emotions, changing caregiver perceptions about the illness, and facilitating better communication between the caregiver and the service user [45].
In five studies, financial problems were related to various factors; for instance, no medical insurance coverage for all treatment or medications, recurrent episodes of disease, insufficient services of caregiving, cost of continuing the treatment programs, or no financial support for family, as well as related to the patient's socio-occupational dysfunction and unemployed status [9,11,12,44,46]. Two studies [9,13] addressed caregiving responsibilities and included following up on medical appointments, managing medications, guiding other family members to take care of the patients, motivating the patients with their daily activities, helping patients to perform self-care activities, and spending more quality time with the patients. Additionally, many families contend with caregiving difficulties associated with such issues as managing the patient's symptoms, the patient's refusal to take medication, uncontrollable patient behavior, and the patient's lack of self-care [44,45]. Interestingly, due to the full commitment of these care giving roles and patient dependency on caregivers, caregiving tends to interfere with a family's daily lifestyle and related responsibilities. This in turn causes caregivers to neglect issues relating to themselves and often including the exclusion of various activities and social interactions, the impact on their relationship with relatives with SMI, the affect on their quality of life both socially and economically, and the objective and subjective burden to which they are subjected [9, 11-13, 44, 46]. Also, the attitude of family members toward the mental illness and a lack of knowledge about SMI influenced the caregiving process and family relationships [9,44].
Family social isolation was evident in five studies, and was related either to a lack of social support or stigma or to the effect of illness and medications. Families experienced isolation because of involvement in the caregiving process and the characteristics of disease [11], and experienced exclusion and lack of support from friends, relatives, and their communities [12,46]. Family caregivers and their relatives with SMI experienced public stigma, which impacted a family caregiver's coping, employer recruitment practices, and family functioning, and caused delays in seeking professional health care, loss of social support, and increases social isolation [9,11,44,46]. Furthermore, families isolated themselves or avoided people because they were hiding the disease, and felt embarrassment because of their relative's illness [9,44]. Due to having to provide care for a patient, as well as various factors such as incomplete patient recovery, symptomatic phases, patient emotional reactions, side effects of anti-psychotic medications, and cognitive impairment, families gradually become more isolated from society and more socially withdrawn [11,44,46].
Psychological distress was evident in five studies and was described as the psychological disturbance experienced by family caregivers throughout their relative's illness trajectory. Frequently, this distress was described in terms of guilt, where the caregivers blamed themselves for the disorder or for failing to know about the illness [44,46] and worried about the uncertainty of such factors as the patient's future, the caregiving process after they died, unpredictable illness, and how the patient could fit in and maintain a job in society [11,[44][45][46]. Additionally, feelings of loneliness were described in three studies [11,44,46]. Caregivers felt especially sad and anxious when taking care of patients in crisis situations [44,46]. Furthermore, anxiety and fear were related to ambivalence to contact healthcare providers to manage the crisis situation [46]. Family caregivers also experienced feelings of hopelessness about patient recovery, feelings of being incompetent and unqualified to provide care with emotional disconnection, and feelings of loss of interest and self [12]. One study reported reported that siblings experienced grief about their relatives [9].

Positive Aspect of the Caregiving Experience
Families perceived themselves as the only supportive resource for their relative with SIMs in that they were accepting and assumed their caregiving role as a part of their lives [12]. A positive experience of caregiving was identified in one study as families continue to enjoy providing care to their relatives with SMI as it is as part of their responsibility and a part of their lives [12].

Coping Strategies Adopted by Caregivers
Caregivers use a broad range of coping strategies to assist and support with patient illness and caregiving necessities. Three articles addressed the most emotional focused approach; these included accepting caregiving roles, looking for emotional support, sharing their feelings and difficulties with other, and using religious and spiritual approaches [11][12]44]. Furthermore, three studies illustrated that problem-focused approaches were used in seeking advice from family members, overcoming problems, and involving caregiving activities and regular tasks [9,44,46]. However, two studies reported that families used escape-avoidance as a coping strategy from the caregiving process [9,44]. One study explained the caregiver's self-care activities; for example, engaging in leisure activities and adapting relaxation activities, including chatting with friends, listening to the radio and watching television, and enjoying meals with family [46].
Two studies revealed that cultural beliefs regarding mental illness, as well as caregiver's spiritual strategies, tend to be the primary reason for family caregivers seeking traditional, religious, and faith healing treatments to cope with their relative's disorders [11,13]. These practices were based on existing cultural beliefs embedded in the caregiver's community that mental illness is a result of -previous deeds, black magic, or God's curse, possession of evil spirit‖ [9]. However, one study found no increase in family religious beliefs during the illness process [45].

The Synthesis of Findings
This systematic review synthesized the non-Western evidence of the experiences of family caregivers in providing care for persons with SMIs. The integration results from this review revealed that the quantitative studies described the most frequent factors that are associated with a family caregiver's challenges. The qualitative studies illustrated the high level of complexity associated with family caregiving experiences. These difficulties were significantly exemplified with regard to the levels of burden and stigma, and the elevated levels of emotional responses, including feeling overwhelmed and being socially isolated. Further, it was noted that families used different coping skills with their everyday activities relevant to their caregiving and in overcoming various obstacles. Overall, it is evident that throughout nonwestern countries, regardless of the culture, age or socioeconomic status, caregivers are experienced similar frustrations. More frequently, many caregivers find that their coping skills promote additional unmet needs and requisite support strategies.

DISCUSSION
This systematic review aimed to analyze the experiences of family caregivers of patients with SMI in non-Western countries. Most of the studies used descriptive quantitative and qualitative studies. Therefore, it is important to develop intervention studies to improve caregiver burden, to teach family caregivers how to adapt to lower their stress, and to prepare these caregivers for their caregiving role. Further, studies used various tools with varied constructs such as burden, stigma, coping, and psychological distress to measure and overlap using different scales. Also, researchers in those studies tested relationships between caregiver burden, psychological problems, stigma, personality traits, social support, and self-esteem, and found significant relationships between or among variables. Also, the researchers tested relationships between caregiver burden, psychological problems, stigma, personality traits, social support, and self-esteem, and found significant relationships between or among variables.
All caregivers included in these studies were close family members to the person with SMI for whom they were caring. Caregivers were different ages and the majority of them in the research were parents, spouses, siblings, and adult children. The caregivers' burden of patients with mental illness tends to be high across most of the studies. Hence, findings from the review indicated caregiver burden is highly associated with female caregivers, older age caregivers, a long duration of caregiving, low education levels, unemployment, economic costs related to treatment and to the patient's illness, low health status, experience stigma, a lack of family support, their relationship with patient, and type of patient diagnosis. These findings are consistent with the study conducted in Western countries, which found a family's mental health difficulty within one year was significantly increased among female caregivers under the age of 65 [47]. Other factors included marital status (divorced, widowed, or single), a low education, a low household income, and the presence of a mental health diagnosis for families who perceived a high level of burden.
Notable factors influencing experiences were the contradictory findings of the caregiving burden for the male with SMI. In Saudi Arabia, the high level of burden is associated with caring for female patients with SMI [21]. A study explained these differences based on the Arab culture in which people handle any issue related to females with SMI in secrecy due to two reasons: limiting their chance of marriage and being incapable of caring for their children [21]. In Saudi Arabia, it was surprising to find only one quantitative study on family caregivers and no qualitative studies.
The finding of this review also revealed that perceived burden, stigma, and psychological distress detected in caregivers of persons diagnosed with schizophrenia was greater than for patients with other SMIs. This finding is consistent with several studies within Western countries; the difference may have arisen from disease characteristics of the patient [48][49]. In addition, patients with schizophrenia have a higher rate of symptom relapse and recovery [50]. Therefore, patients with schizophrenia need a longer duration caregiving and treatment due to frequent hospitalization.
The systematic review found that the burden perceived by caregivers is associated with variables such as depression, anxiety, anger level, and social support. It was clear that caregiving responsibilities lead to the development of psychological and physiological problems or predict these problems and make it difficult to provide patient care. This finding is in agreement with a systemic review that 46% of caregivers reported depression and anxiety, which are related to the caregiving relationship [51]. Depression and anxiety were found to be related to being a female caregiver, clinical features of the illness, and duration of care [52].
The systematic review highlighted that family caregivers used different coping strategies and self-care activities to deal with caregiving activities or crisis situations. Furthermore, the review found that family coping styles were associated with caregiver burden. These finding were similar to a study [53] that family caregivers of persons with SMI used various problemand emotion-focused coping strategies to deal with a mental health crisis and to prevent the negative impact of stigma and family burden. Furthermore, the review found that families were seeking traditional or religious and faith healers for treatment or to cope with their situations based on cultural beliefs. Therefore, healthcare professionals need to help caregivers enhance their coping skills, to support their existing skills, and to facilitate the development of new ones [54].
The systematic review revealed that family caregivers experienced a lack of formal and informal support and of mental health care resources, which had an impact on their psychological well-being, family burden, and financial issues. The findings of this review demonstrated that communication and education from health care professionals are important to caregivers. Also, caregivers experienced social isolation due to providing care, a loss of social support, stigma, illness and medication side effects, and attitudes toward their relative's illness. Social and cultural background may play a role in the burden of caregiving and caregiver perceptions. One study reported that there is a higher level of stigma and negative conceptualizations of the illness, which leads caregivers to try to keep the illness a secret and to delay seeking treatment [55].
Even though the non-Western studies shared similar findings, limited studies have examined the supports available, the needs of family caregivers of patients with SMI, and the positive aspect and rewards of caregiving experiences in non-Western countries.
Cultural differences in each country affect the burden experienced by each family as caregivers. Families need support when caring for patients and need service and support for their own mental and physical health in order to sustain their caregiving role. Limited research was found on needs of these caregivers for professional support. Caregivers need information, accessibility of care, and communication with a professional. Also, family caregivers need support in gaining confidence in their ability to cope and in managing the patient behaviors, and should not be ignored by professionals. Furthermore, due to differences in healthcare systems and culture variation, caregivers in Saudi Arabia might have different experiences. More qualitative studies of Saudi caregiver experiences with persons with SMI are warranted to gain further understanding of family caregiving experiences and to develop culturally appropriate intervention studies in Saudi Arabia.

CONCLUSION
This systematic review of the studies was conducted to synthesize the recent evidence about family caregivers' experiences of caring for patients with SMI. The review included qualitative and quantitative studies and found most were conducted on caregivers for schizophrenia, bipolar, and major depressive disorders. Despite that family caregivers of patients with SMI have moderate to severe levels of burden, the review found that there was an impact on the caregiver's health, psychological well-being, and coping skills. Many family caregivers do not report symptoms or seek mental health-specific services for help regarding their needs. Therefore, a psychiatric mental health nurse should conduct a comprehensive psychiatric evaluation of family caregivers on a regular basis. The psychoeducational and nursing interventions for caregivers based on the needs of caregivers are important.
On the other hand, the review found a few intervention studies that could uplift these burdens and improve the coping skills of caregivers. Furthermore, more experimental and qualitative studies with different sample groups in non-Western countries should be considered in the future. Further research is required to apprehend social and professional support in this context. Planning and implementing early psychosis support programs as well as long-term interventional programs such as those commonly implemented in Western countries may also provide important contributions to caregivers. The mental healthcare system must plan comprehensive interventions to meet caregiver needs. It is necessary to develop approaches that improve knowledge about mental health and mental disorders and that support best practice interventions. These would decrease not only the burden on caregivers but also improve their quality of life.