BACKGROUND

Depression is one of the most common mental disorders (Regier et al,1988) and refers to the emotional disorder representing worry, gloom, helplessness, and unawareness ranging from emotional mood changes to morbid condition (Beck et al, 1961) and thus is a total disorder that affects individual’s ability to control thought and behavior due to feeling of helplessness or sense of loss (Holmes, 2002).

In the psychoanalysis glossary, depression is described as affect, i.e. the complex psychophysiological state that includes cognitive and physiological elements as it is the subjective mood such as feeling of sadness, hopelessness, lethargy, guilty feeling, self-critical thought, and reduced interest in outside activities, and the symptoms for the progression of depression include typical boredom, fatigue, reduced sexual desire, loss of appetite or gulosity, constipation, insomnia, and sometimes increased sleep time. Blazer(2003) claimed that depression appears as a reaction to stress and is in the continuum from the normal mood changes to the morbid condition and the level depends on individual’s degree of adaptation.

Overall, depression can be classified into three meanings: the first is depression as symptom, which means depressed mood or state, the second is depression as syndrome and means cluster of depressive symptom, and the third is depression as disorder and means a series of clinical characteristics or psychological condition accompanied by impaired function

(Bae, 2006). Depressive symptoms occur by the negative cognitive system of oneself, environment, and the future, and much stress is highly likely to lead to depressive disorder (Kim and Lee, 2000). The main factors of depression are loneliness, economic difficulty, recent experience of stress, family history, experience of psychological damage and violence, alcohol intoxication, drug abuse, unemployment, health problems, and pain (Goldberg, 2006; Park, 2011), and the depression of caregivers looking after the patient is a complex process, but influenced by the patient or caregiver’s general characteristics, ethnicity, and cultural things (Kenneth et al, 2003).

To look at the caregiver characteristics, when the caregiver lacks economic resources, when the caregiver is a daughter or spouse, when the caregiver spends a lot of time in care activity, and when caregiver’s health condition is deteriorated, depression appears high (Levine, 2003), whereas in case of patient characteristics, when the patient state is bad, when the patient is young, when the patient needs caring activity a lot due to deteriorated activities of daily living, and when the problem behavior is severe, depression appears high (Kenneth et al, 2003).

Schulz et al.(1995) demonstrated as a result of considering 41 precedent studies to identify the family caregivers’ degree of physical and mental illnesses that according to the CES-D(Center for Epidemiologic Studies Depression Scale), depression score was 7.4-9.4 point on average in general population group, whereas it was 14-18 point on average in family caregiver group. In all studies investigated, family caregiver’s depression score appeared high.

The dementia patient caregiver’s depression is negative to the caregiver

himself, but if caregiving is compared to one occupational task, the difficulties in caring and maladjustment from depression will have a negative impact on dementia patient.

Since caregiver’s depression status from dementia patient care may lead to the stage of depression as disorder, which influences the daily living and even the entire life, it seems necessary to make a more detailed analysis of caregiver’s degree of depression and the influencing factors and seek the steps and timing of intervention depending on the results from the study.

1. Dementia Patient State and Depression

The precedent studies on the factors that have an impact on depression in dementia elderly family caregivers reported that care situations including dementia elderly’s activities of daily living (ADL) or problem behavior (BPSD) and family caregiver’s coping style and social support have an impact on family caregiver’s depression (Ma and Kim, 1995; Kim, 2002) and that the higher the dementia elderly’s dependence in activities of daily living and the more severe the problem behavior is, the bigger the family caregiver’s depression or stress is (Brodaty and Luscombe 1998;

Meshefedjian et al., 1998).

And most studies reported that the more the restrictions on dementia patient’s daily activity, caregiver’s depression increases (Pinquart and Sörensen, 2011; Sung, 2006; Covinsky, 2003; Cho, 1996; Kim, 2001; Yoon et al., 2000; Wright et al., 1994).

2. Care Activity and Depression

Caregivers looking after the senile dementia patient at home spend a lot of time in caring (Stevenson, 1990). Park et al.(2005) reported that caregivers looking after the dementia patient for more than 15 hours occupy 45%. As they have to be with the dementia elderly for all day long, they are isolated from the society and their physical health is aggravated, and simultaneously with the increasing care burden, depression also worsens (Park, 2015).

3. Care Burden and Depression

Many studies have reported on the relationship between the burden that the dementia patient caregivers feel and the depression (Ryu, 2017, Hong, 2017, Park, 2015). Park(2015) found that care burden, subjective health condition, care period, occupation, self-efficacy, quality of marital relationship before caring, and social support in order had an impact on depression and so care burden was found to be a variable that had the biggest impact. It can be said that the caregivers looking after the dementia elderly at home are isolated from the society and their physical health is aggravated because they have to be with the dementia elderly for all day long and at the same time as their care burden increases, their depression also gets severe.

Ryu(2017) reported that there is a high correlation between dementia patient caregiver’s care burden and depression, but both cannot be said as

the same concept and regarded that there are a lot of different opinions about the directivity. They saw that unlike the care burden that individuals feel because they give care for dementia patients, depression is a psychological construct that is influenced by different states other than care situations including care burden and so care burden is a predictor of depression.

The statistical association that care burden has an impact on depression has been supported by the past other studies, too (Bell et al, 2001; Clyburn et al, 2000). On the other hand, there is a study finding that reported that depression is dementia patient caregiver’s determinant of care burden (Kim et al., 2001)

Taken the precedent studies above together, the existing studies reporting that the care burden toward dementia patients has an impact on nursing provider or care provider’s depression have been accumulated and especially care burden from the behavioral characteristics of dementia patients may have a much stronger impact on depression. Accordingly to draw up the measures to reduce the pain of family caregivers, this study aims to make a more detailed review of the factors that family caregivers may have on depression.

B. Care Burden

Care burden is caregiver’s stress from the elderly’s physical dependence and lack of ability in caregiver’s caring process (Poulshock and Deimling, 1984) and so refers to the emotional, physical, social, and financial

difficulties and inconveniences experienced by caregivers in a situation or accident like patient’s change of behavior or state (Zarit, 1980).

About such burden, Clausen and Yarrow from England began to identify the problem of families taking care of the mentally-disordered people in 1955 and Grad and Sainsbury(1963) began to research the burden that families felt and the effects while expressing the responsibility and tension of the families taking care of the mentally-disordered people with the term care burden (Gater et al., 2014). Since then, care burden has been recognized as negative product of care, and many studies explain that care burden is the factor that causes stress, tension, and pain to the main caregivers taking care of the dementia patient (Donaldson et al, 1998).

Zarit et al.(1980) conceptualized family caregiver’s burden as emotional, physical, social or economic stress that caregivers undergo while taking care of the patient based on the subjective feelings of negative experiences, and Thompson and Doll(1982) expanded the concept care burden into the objective burden as well as subjective burden. Subjective burden is defined as caregiver’s subjective feeling and this is expressed with worry, inconvenience, embarrassment or anger, which are the emotional reactions experienced in the caring process, and objective burden is related with the changes that happen in caregiver’s life and the degree of collapse of his life and so expressed with the degree of negative effects that have on social and socializing activity due to care time, number of tasks, and financial tension. Montgomery et al.(1985) also defined care burden as ‘a certain fear or guilty that family member vaguely feels while taking care of the patient.’

Besides, Novak and Guest(1986) defined care burden as burden from the

shortage of time because too much time was spent for the elderly patient and divided this concept into the time-dependent stress due to shortage of time and the self development stress that is caused when disrupting the self development. Kosberg and Cairl(1986) saw care burden as the cost that has to be paid as a result of care and classified it into the following dimensions: restrictions on social activity, restrictions on personal life, economic cost, and value of providing protection, stress from the relationship with the elderly, and mental and physical difficulty. And Zarit et al.(1986) made an approach from the perceived point of view and for definition, classified it into emotional wellbeing, physical health, social life, and economic state perceived as a result of families taking care of the patient, as the degree of recognizing how painful caregiver’s situation is in taking care of the patient. Bull(1990) defined care burden as ‘stress that caregivers receive in a situation that patient’s self-care function is restricted and patient is depressed due to physical health condition, functional disturbance, and mental health, and divided stress into subjective stress and objective stress. Subjective stress is the negative things such as feeling, attitude, and emotion that caregivers feel in the caring process, and objective stress is the deeds and duties that families have to do and necessary resources according to the patient’s needs.

And regarding the factors of care burden, Yap et al.(2005) claimed that care burden has three major factors: the first is the caregiver’s personal life factor, the second is the negative feelings related to support factor, and the final is the effects of feelings that need to be given to the patient.

In the studies on care burden, the most universally accepted concepts are subjective burden and objective burden, which are more expanded to

encompass the physical symptoms like fatigue and lack of sleep and psychological symptoms like depression, anger, anxiety, and guilt, which can be experienced by caregivers as a consequence or result of care and social and economic problems including isolation and leisure activity restrictions multidimensionally (George and Gwyther, 1986; Lee and Kim, 2003; Han et al., 2015; Kang et al., 2017).

To reduce the care burden, with the expanded concept of care burden, there is a need to analyze the factors that have an impact on care burden in various ways.

1. Dementia Patient State and Care Burden

Care burden is primarily associated with the characteristics of care experienced by caregivers, in other words, the symptoms that dementia patients show. The Ministry of Health and Welfare(2009) claimed that the biggest impact on dementia caregiver’s burden, among degraded cognitive function, failure in daily living activity, and problem behavior that dementia patients show is patient’s problem behavior. In measuring the group of neurobehavioral symptom with Zarit’s care burden scale, it appeared that the more the subjects’ problem behavior, caregivers felt burden and depression. In the group of neurobehavioral symptom, restlessness or aggressive attitude aggravates the relationship with caregivers and the aggravated relationship again causes more severe behavioral problems from the patient who receives care, which is a repetitive vicious cycle (Rachel et al., 2005).

Also in Pinquart et al.(Pinquart et al., 2003) who made a meta-analysis

of 228 care burden studies, patient’s neurobehavioral symptom is a strong predictive factor of dementia care burden than any other factors, many roles that have to be performed by caregivers cause conflict, which leads to the conflict in the entire family interaction if the role readjustment in a family fails (Kwon et al., 2002), and this may be a factor that can give severe care burden to all the families.

Besides, neurobehavioral symptoms unadjusted of dementia patient like aggression, in fact, add to the caregiver’s burden as a factor that cannot accept the patient into the nursing facility. Song et al.(2013) claimed that dementia severity is judged as cognitive disorder, neurobehavioral symptom, and deteriorated activities of daily living and the dementia severity increases the main caregiver’s care time and the care burden as well.

Especially in the damaged cognitive function, main symptom of dementia among the dementia elderly related characteristics, the greater the extent of damage, the higher the family caregiver’s care burden increases (Bae et al., 2006; Ma, 1998; Kim and Choi, 1993) and dementia elderly’s impaired activities of daily living also have a strong impact on care burden (Kim and Choi, 1993; Lee et al., 2015). Cho et al.(2010) maintained that going to the bathroom, moving, toilet training, and eating, among the activities of daily living have a statistically significant impact on care burden.

2. Care Activity and Care Burden

Various causes of care burden that the dementia patient caregivers feel have been presented, but among which, care activity is emphasized. In

other words, dementia severity increases the main caregiver’s care time and raises the care burden depending on the degree (Song et al., 2013), and if the effort and time for looking after dementia elderly increases due to dementia elderly’s problem behavior and dependence, the caregiver feels substantial care burden in physical, emotional and economic aspects (Lee et al., 2008).

The important factors that have an impact on caregiver’s burden are care period, time for providing care in a day, and care intensity. As the social supports network collapses by the long-term care, social isolation deepens and caregiver’s care increases.

And Kwon et al.(2015) mentioned after analyzing multiple precedent studies on care burden that care time has an impact on care burden and one of the painful factors of care burden that dementia elderly caregivers especially feel the most strongly is the relationship between role constriction and care time. Due to the role constriction that threatens even the existing everyday life, caregivers lose their sense of self and lead to anger at the patient, and the burden from the role constriction is aggravated as the time to look after the patient increases and so the care time cannot be separated in understanding care burden. The more the care time becomes, the care burden increases and if one should take care for all day, care burden appears greatly and care burden diminishes if shared rather than if taken care alone, and so this showed a close association between care time and care burden.

Also, Kim et al.(2004) analyzed the precedent studies and summarized as follows the significance of utilizing care time to evaluate the care burden more objectively. If the caregiver spends time in caring for the

dementia patient, the time for doing a productive work lessens relatively, which reduces the income in the end. Therefore, measuring the care time can be an indirect indicator of economic burden by the dementia and so used as efficacy measurement index in the drug trial research on dementia patients. And it was said that care time has a significant correlation with the depth of dementia symptoms like functional disorder and failure in activities of daily living and also has a significant correlation with caregiver’s stress and inconveniences.

Other opinions on care time have been reported. It is predicted that if social supports network collapses by the long-term care, social isolation deepens and caregiver’s burden increases, but Zarit et al.(1986) reported that as the period of outbreak elapses, the care burden becomes low and Mun(1998) claimed in the analysis on the routes for the quality of life of dementia elderly and families and their social welfare support plans that burden worsens in early stages of dementia. Monteko(1989) also reported that the longer the disease duration becomes, frustration diminishes. It is predicted from this that acceptance of care and adaptability to it increased.

C. Social Support and Social Activity

Social support means help and aid provided by family, friend, neighbor, and others (Park, 1985) and in multidimensional nature of social support concept, social support is classified into four categories: material support, informative support, emotional support, and self-esteem support (Cohen and Hoberman, 1983) or social support is conceptualized into emotional support,

informative support, material support, and evaluative support (Park, 1985).

Like this, every researcher presents different conceptual classifications.

At this time, emotional support means stability that one’s feelings are understood through sympathy and one receives positive attention from others, and includes emotional support provided by others when one is in trouble (Sherbourne and Stewart, 1991). This is happened through unofficial channels from close people like family, friend, and special people rather than through official channels. Substitute family means the presence of substitute family who can support household affairs including housework instead of main caregiver and keep the patient state or handle inconveniences. Finally care support means being provided education about in-home service agency and facilities and education necessary for looking after patients.

There has been no consensus on the conceptual definition on social activity. Every researcher has defined it in various ways: participation, social activity, social integration, or involvement in society (Gi, 2019).

Likewise, social activity is also called as social participation activity, has a similar meaning to social integration as a contrast to social exclusion or alienation (Park Changje, 2015), and refers to involvement in volunteer activity, hobby activity, leisure gathering religious event, community action, income seeking activity, leisure event, educational activity, and civic group (Park et. al.(1994).

Aging Panel Survey (2014) classifies social participation into the following six types: religious activity, socializing activity, leisure activity, reunion and clan gathering activity, volunteer activity, and party and civic group activity, and defines social participation as social activity in a limited

sense and one’s exercise of right activity in the broadest sense.

1. Social Support’s Moderating Effect

Social support serves as an important factor that predicts depression (Rho and Mo, 2007; Lee et al., 2004), and Park(2009) reported that in the group of living with families, social support and family support are high and so the level of depression is low. Also in Park(2011) on the relationship between social support and depression, it appeared that if the social support is high, the depression prevalence rate is low at 3.4%, and if the social support is low, the depression prevalence rate is very high at 36.4%. Like above, the precedent studies suggested that social support is a factor that has an impact on depression.

Domestic studies also regard social support as important dependent variable that has a direct impact on family caregiver’s care burden, but Park and Park(2015)’s recent study on the moderating effect of social support reported that the entire effect of social support is at the middle

Domestic studies also regard social support as important dependent variable that has a direct impact on family caregiver’s care burden, but Park and Park(2015)’s recent study on the moderating effect of social support reported that the entire effect of social support is at the middle