{'fraction_non_alphanumeric': 0.05020465260867313, 'fraction_numerical': 0.027511527900108804, 'mean_word_length': 5.106295476115154, 'pattern_counts': {'":': 0, '<': 12, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
The impact of psychiatric disorders on caregivers: An integrative predictive model of burden, stigma, and well‐being

Abstract Purpose The study investigates the predictors of caregivers' experienced burden, stigma, and well‐being, when looking after family members diagnosed with a psychiatric disorder. Design and Methods This cross‐sectional study included 168 caregivers; perceived burden, stigma, well‐being, knowledge, illness perception, and medical variables were assessed. Findings A number of correlates of burden, stigma, and well‐being have been identified and are being discussed. The integrative predictive model showed that the caregiver's emotional representation of illness best predicts burden (β = 0.38, p < 0.001), stigma (β = 0.53, p < 0.001) and well‐being (β = −0.36, p < 0.001). Practice Implications Our results can enable health professionals to tailor psychosocial interventions addressed to family members of individuals living with a psychiatric condition.

Regardless of the age of the patient (e.g., children, adolescents, or adults), the caregiver role is associated with feelings of burden, health-related difficulties, and lower well-being (Baker et al., 2011;Bom et al., 2018;Estes et al., 2009).
Caregiver burden (Gérain & Zech, 2019;Liu et al., 2020;Sołtys & Tyburski, 2020;Tsai et al., 2021) is a concept that refers to the physical, emotional, and mental exhaustion or depersonalization a caregiver can experience (Gérain & Zech, 2019;Thompson et al., 2014) and it has been shown to have a negative impact on both the caregiver and the patient (Oruche et al., 2012). Caregivers' gender (i.e., female), educational level, professional status, financial difficulties, number of hours spent caregiving, and other psychosocial aspects (e.g., depression and anxiety levels, coping mechanisms, social isolation, etc.), all influence the level of burden experienced (Adelman et al., 2014;Gérain & Zech, 2019). Some of these risk factors (e.g., gender, marital status, mental health status, etc.) are also known to influence caregivers' well-being (Chappell et al., 2014) which in turn impacts the patients' well-being and overall recovery (Schulz & Sherwood, 2008).
The literature has predominantly focused on the impact chronic conditions (e.g., Down syndrome, autism, sickle cell disease, dementia, Alzheimer's disease, cancer, stroke) can have on caregivers, especially in terms of burden, quality of life, and well-being (Adelman et al., 2014;Barros et al., 2017;Carden et al., 2016;Jeyagurunathan et al., 2017;Macedo et al., 2015;Sheng et al., 2018). Recently, other variables such as illness perception or stigma about mental health have become topical (Han et al., 2021;Hinshaw, 2005;Zhang et al., 2018). For example, parents of children diagnosed with a psychiatric disorder have been reported to have a tendency to blame themselves for their child's condition (Hasson-Ohayon et al., 2019). More so, they appear to incorporate stigmatizing attitudes and knowledge about the disorder in their general representation of the condition (Hasson-Ohayon et al., 2019;Moses, 2010;Zhang et al., 2018), which can have an impact on the child's health outcomes (Hasson-Ohayon et al., 2019;Moses, 2010). Previous evidence has also shown illness perception impacts patients' adherence to treatment (Bassi et al., 2015), caregivers' coping strategies (Al Anbar et al., 2010;Bassi et al., 2015), as well as the well-being, anxiety, and depression for both patients and caregivers (Bassi et al., 2015).
We believe this study can help tailor future psychosocial interventions for family members of patients with psychiatric conditions. We know from previous research that psychiatric genetic counseling can improve knowledge (Hippman et al., 2016), reduce stigma (Costain et al., 2012a(Costain et al., , 2012b, and increase empowerment and self-efficacy (Austin, 2019;Inglis et al., 2014;Semaka & Austin, 2019) in patients living with psychiatric conditions. Recent studies have focused on tailoring psychiatric genetic counseling for parents of children with psychiatric conditions (Griesi-Oliveira & Sertié, 2017; Haakonsen Smith et al., 2017;Hoang et al., 2018). These psychosocial interventions, among others (e.g., cognitive-behavioral therapy, mindfulness-based interventions, stress-management programs, etc.), are undoubtedly a promising option for families as they are aimed to specifically target understanding and adaptation to conditions with familial implications (Resta et al., 2006).
Given the complex nature of the caregiver's role and the impact it has been shown to have on the emotional, psychological, and physical health of both patients and caregivers (Bom et al., 2018;Jeyagurunathan et al., 2017;Revenson et al., 2016), we aimed to investigate the main predictors of caregiver's experienced burden, stigma, and well-being when looking after family members diagnosed with a psychiatric disorder. It is designed to measure levels of burden and distress among family carers of people with a severe mental illness. IEQ has 31 items on a five-point Likert scale (never, sometimes, regularly, often, and always) looking at (1) tension between family members and the patient (nine items); (2) supervising and supporting the patient's condition on a daily basis (e.g., sleep, medicine intake, etc.) (six items); (3) worrying about the safety and future of the patient (six items); and (4) urging the patient by motivating, activating and stimulating him/her toward self-care (eight items). The internal consistency of the scale varies for the four subscales from 0.68 to 0.86, with 0.87 to 0.91 for the sum score and a high test-retest reliability (van Wijngaarden et al., 2000).

| Self-Stigma in Relatives of People with
Mental Illness Scale (SSRMI; Morris et al., 2018) It is a 30-item scale that measures self/internalized stigma among family members of individuals with a psychiatric diagnosis.
Each statement can be answered on a five-point Likert scale, from 1 = strongly disagree to 5 = strongly agree. The internal consistency is α = 0.90, and the test-retest reliability as well as the construct reliability were also found adequate. Factor analysis was performed and concluded one single factor explained 29.57% of the variance, with 26 of the total 30 items having significant loadings on the factor (Morris et al., 2018).  Dupuy, 1990;Grossi & Compare, 2014) It is a 22-item scale that measures subjective psychological well-being. It has six subscales: anxiety, depression, positive well-being, self-control, general health, and vitality (Grossi & Compare, 2014 Lobban et al., 2005) It is an adapted version of the IPQS-relatives, which was originally designed for schizophrenia. The original wording was adapted for the purpose of this study to reflect the parent-child relationship (e.g., this questionnaire aims to assess how you perceive your child's mental health problem). IPQ-relatives has the following subscales: identity (58 items), cause (26 items), timeline-acute/chronic (6 items), timeline-cyclical (4 items), consequences for the patient (11 items), consequences for the relative (9 items), personal control-patient (4 items), personal control-relative (4 items), personal blame-patient (3 items), personal blame-relative (3 items), treatment control/cure (5 items), illness coherence (5 items), emotional representation (9 items). Each item can be rated on a five-point Likert scale, from 1 = strongly disagree to 5 = strongly agree. The internal consistencies of the subscales vary from 0.63 to 0.83, with the exception of one subscale, the personal blame-relative subscale which has an internal consistency of 0.43 (Lobban et al., 2005).

| Data analysis
Data collected in this cross-sectional study was analyzed to explore the main predictors of caregivers' experienced burden, stigma, and well-being. In the first phase, the descriptive statistics and correlation analyses for all variables included were computed. In a second phase, to explore the best predictors of the investigated variables, three predictive models were computed using linear regression analysis.

| Sociodemographic correlates of burden, stigma, and well-being
The matrix correlation showing the relationship between burden, stigma, well-being and the sociodemographic variables is shown in Table 2. Of all demographic variables, age and gender are most informative. Age was positively associated with burden (r = 0.193, p < 0.05) and gender was positively associated with both burden (r = 0.206, p < 0.05) and stigma (r = 0.199, p < 0.05). Table 3 We also looked at the correlation between burden, stigma, wellbeing, and family relationship. Our data show that having a parent with a psychiatric condition is positively associated with the burden (r = 0.188, p < 0.05), while being the partner of someone with a psychiatric diagnosis is positively associated with stigma (r = 0.273, p < 0.01) and negatively associated with well-being (r = −0.159, p < 0.05). Interestingly, being a parent of a patient with a psychiatric condition is negatively associated with stigma (r = −0.167, T A B L E 3 The matrix correlation for the relationship between burden, stigma, well-being, and family relationship  Table 5.

| An integrative predictive model of burden
To select the relevant predictors of the burden from each category of correlates (i.e., sociodemographic/familial, medical, and cognitive), we tested inside each category the predictive value of the relevant factors whilst controlling for the rest of them. Our data show that in the sociodemographic/familial category, the significant predictors were age (β = 0.17, p = 0.038) and gender (β = 0.21, p = 0.008). In the medical category, the only significant correlate was alcohol use disorder (β = 0.16,p = 0.043), and in the cognitive category the only significant predictor is emotional representation (β = 0.26, p = 0.009).
Consequently, these predictors were simultaneously introduced into a multiple linear predictive model of burden. Results are presented in Table 6.
The tests performed to verify if the data met the assumption of collinearity indicated that multicollinearity was not a concern, all variance inflation factor (VIF) values being less than 10 and all

| An integrative predictive model of stigma
As in the case of burden, to select the relevant predictors of stigma from each category of correlates (sociodemographic/familial, medical, and cognitive), we tested for each category the predictive value of the relevant factors whilst controlling for the rest of them. The results show that in the sociodemographic/familial category, the significant predictors were gender (β = 0.18, p = 0.016) and the life partner status (β = 0.22, p = 0.008). In the medical category, the only significant correlate was alcohol use disorder (β = 0.22, p = 0.004), and in the cognitive category, the significant predictor is emotional representation (β = 0.40,p < 0.001). Consequently, these predictors were simultaneously introduced into a multiple linear predictive models of stigma. Results are presented in Table 7.
The tests performed to verify if the data met the assumption of collinearity indicated that multicollinearity was not a concern, with all VIF values being less than 10 and all Tolerance values above 0.1.
As results show, when simultaneously controlling for all relevant factors, the only significant predictor of stigma remains the emotional representation of illness (β = 0.53, p < 0.001), which shows that a higher negative representation of the condition predicts a higher level of stigma.  Table 8.

| An integrative predictive model of well-being
The tests performed to verify if the data met the assumption of collinearity indicated that multicollinearity was not a concern, all VIF values being less than 10 and all Tolerance values above 0.1.
Our results show that when introducing the most relevant predictors of well-being into an integrative model, the only significant predictor remains the emotional representation of illness (β =−0.36, p < 0.001). This indicates that a less negative representation of the condition predicts a higher level of well-being.

| DISCUSSION
Our main aim was to identify the main predictors of caregivers' experienced burden, stigma, and well-being when looking after family members diagnosed with a psychiatric disorder. The caregivers in our study were predominantly female, with an average age of 48 years old, living in urban areas, married, and employed. Most patients had been diagnosed with depression, bipolar disorder, anxiety disorders, alcohol use disorder, psychotic disorders, ADHD, and autism spectrum disorders and were looked after by parents, partners, or children. Similar to other studies (Adelman et al., 2014;Chappell et al., 2014;Tsai et al., 2021), our data showed that caregivers' gender was positively associated with burden and stigma, with women feeling more burdened and stigmatized than men. Also, having a parent with a psychiatric disorder was associated with burden, but not with stigma and wellbeing, while having a partner with a psychiatric disorder was mainly associated with stigma and lower well-being, but not with the burden.
Our results also show that having a child with a psychiatric disorder was negatively associated with stigma. This finding is particularly interesting given the relatively small number of studies exploring parents' stigma (Han et al., 2021;Hinshaw, 2005;Zhang et al., 2018), with most studies focusing on parents' well-being, burden, and quality of life (Adelman et al., 2014;Jeyagurunathan et al., 2017;Macedo et al., 2015;Oruche et al., 2012;Sheng et al., 2018). One potential interpretation is that, as in the case of well-being (Hammersmith & Lin, 2016), stigma might be experienced differently by caregivers of adult versus pediatric patients. A recent study looking at caregivers of young mental health patients from Singapore showed parents felt more stigmatized than sibling or spouse caregivers . In the case of well-being, the explanations for the identified differences may be associated with various demographic and socioeconomic factors (e.g., gender, age, race, marital status, work status, health status etc.), the specific time point in a person's life course when well-being was measured, as well as the measurements used (Hammersmith & Lin, 2016). For both stigma and well-being, the identified differences between adult and pediatric caregivers clearly need further exploration.
As expected, the burden was associated with stigma, and wellbeing was negatively correlated with both burden and stigma. We then explored in detail the main correlates and predictors of burden, stigma, and well-being. The statistical analysis showed caregivers' knowledge about their family member's psychiatric condition impacts the level of stigma and well-being experienced, but not the burden. Additionally, the perceived consequences for the relative and the emotional representation of the relatives' condition were both found to be positively associated with burden and stigma and negatively associated with wellbeing. Illness representation has been a growing topic of interest in the field of mental health, but mostly from the perspective of patients (Averous et al., 2020). For patients, perceptions of controllability, the sense of coherence, and the negative consequences of the illness were previously associated with greater chances of seeking help and actively engaging in coping strategies (Baines & Wittkowski, 2012). Nonetheless, these representations influence not only the way patients cope with their psychiatric condition (Baines & Wittkowski, 2012), but they appear to impact caregivers as well (Hasson-Ohayon et al., 2019). Studies from Canada, the United States, and Australia showed that parents' illness perception of controllability, consequences, illness coherence, and emotional representations are associated with problem severity, psychological adjustment, and treatment accessibility (Shanley & Reid, 2015); parents' and adolescent' perceptions of illness controllability is associated with self-stigma (Moses, 2010); and parents' illness perception (specifical attribution of control) impacts the level of criticism health but also for their adaptation to the condition (Baines & Wittkowski, 2012;Bassi et al., 2015).
This study is not without its limitations. The sample size is relatively small, therefore results should be interpreted with caution.
Also, of note, our sample is primarily comprised of female participants; this was due to the fact that most caregivers who accompanied patients to the appointments in the Pediatric or the Adult Psychiatry Clinics were female, and this is where the recruitment was organized. Future studies should consider a more gender-balanced sample.
In sum, we can reliably conclude that the caregivers' emotional representation of the patients' psychiatric condition is the strongest predictor of their burden, stigma, and well-being. To better understand the caregivers' experience, how to best support them, and how to better address the difficulties they encounter, future research needs to investigate the impact illness perception has on these variables. Psychiatric genetic counseling is a valuable and effective psychosocial intervention that may help tackle and manage these issues, with benefits for both patients and family members.

| Implications for psychiatric nursing practice
Psychiatric conditions impact both patients and their caregivers.
Looking after someone with mental health difficulties can be challenging; clearly, the experienced burden or stigma can add more pressure on this complex role. Our results show that illness perception (specifically, the emotional representation of the patients' condition) can impact caregivers' burden, stigma, and well-being. As our study has focused on informal caregivers, it is important that future studies explore if these results are also applicable to formal caregivers (e.g., mental health nurses), who often share similar roles as informal caregivers, as well as additional responsibilities. Mental health nurses are mainly trained to work with patients and their efforts are primarily focused on their care and well-being Lakeman et al., 2020;Sampaio et al., 2015). Our study shows that the impact of the diagnosis on family members can be rather complex and profound; nursing practices could consider delivering psychosocial interventions (e.g., support group interventions, skills training, etc.) to support family members of individuals living with a psychiatric condition.

AUTHOR CONTRIBUTIONS
All authors contributed to the study conception and design, material

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

ETHICS STATEMENT
This study was performed in accordance with the Declaration of Helsinki. This study was approved by Babeș-Bolyai University institutional research board. All adult participants were over 18 years old and provided written informed consent to participate in this study.