In 2015, over 45 million people were suffering from dementia. This number is expected to double globally within the next 20 years1. In addition, most people diagnosed with dementia are cared for by family members, friends, and neighbors in their communities. The caregiving burden of dementia is high and the type of care often required is around the clock, for a variety of daily activities like feeding and dressing. In addition, this type of care is often provided unpaid.

Given the intensity of this care, the experience of caregiving for a loved one with dementia can lead to mental health struggles such as depression, and even physical health issues such as cardiovascular disease, within the caregivers2.

It may be particularly hard to maintain positive self-care and engage in de-stressing activities in the context of intense caregiving. Consequently, it is important to find more effective ways to support family caregivers to cope with caregiving stress, to prevent the development of mental health problems such as depression, in order to boost their own mental and physical health, and to help them provide the best care they can to their loved one suffering from dementia.

This is exactly what a team of researchers out of The Education University of Hong Kong and the Chinese University of Hong Kong are studying3. How can cognitive behavioral strategies used in other effective treatments for depression be applied in flexible ways to meet the needs of caregivers, and help them boost their mental health and reduce symptoms of depression in the face of overwhelming caregiving stress?

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A Novel Approach

To address this question, researchers looked in an unexpected place. They focused on exploring research on caregivers who reported positive gains through their caregiving experiences, such as finding a sense of purpose, a sense of personal growth, and increased feelings of closeness with the care recipient. Researchers noticed that how caregivers appraised their stress (i.e. the meaning made from the experiences) influenced their feelings of either sadness, depression, or a sense of purpose and growth.

Researchers hypothesized that by targeting the way caregivers think about their role and the challenges they face, and encouraging them to practice generating more positive appraisals about their caregiving experiences, perhaps they could reduce symptoms of depression. This approach to reducing stress and depression has been applied to other types of stressful events, but has not been applied to the role of caregiving yet.4,5

To test this hypothesis, they recruited 96 caregivers of people diagnosed with Alzheimer's disease. They randomly assigned them to one of three interventions. The first two interventions were standard caregiver support interventions, which involved psychoeducation about dementia itself, and strategies to cope with the specific problems that arise in the process of caregiving.

For example, these interventions provided information about the types of behavioral and psychological problems people with dementia experience, as well as strategies to manage impairment in activities of daily living such as eating, cleaning, as well as the importance of activity scheduling and communication skills. These standard interventions were delivered in person, and one included practical exercises practicing skills to cope with challenges (STD-PE) and the other only included lectures and no practical exercises (SIM-PE). They compared these two interventions to what they called a "Benefit Finding" intervention that included all the same psychoeducation and practical exercises that the STD-PE intervention did, but also included practice with positive reappraisal of challenging caregiver experiences exercises.

Find the Silver Lining

These exercises were based on vignettes of a hypothetical caregiver, describing difficulties in dealing with activities of daily living and the behavioral and psychological symptoms experienced by the care recipient. In this intervention, participants were asked to come up with as many alternative positive appraisals as possible of the challenges, and to imagine how the fictitious caregiver would feel differently with these different types of thoughts and appraisals. In addition, videos of experienced caregivers describing positive gains were provided to model reappraisal success. In-between sessions, participants in the Benefit Finding group were also encouraged to keep journals of positive reappraisals of their own caregiving. Each intervention involved four bi-weekly 3-hour sessions delivered in the caregivers' homes by paraprofessionals with a degree in psychology.

The overall results suggested that caregivers in the Benefit Finding group reported less depression and less role overload when compared to the psychoeducation only groups. Researchers also tested what specific process in the Benefit Finding intervention may be causing the reduction in depression symptoms, and they found that caregivers practice doing positive, benefit-finding reappraisals of thoughts lead to an increased perception of ability to control upsetting thoughts, which predicted reductions in depression.

This is a particularly interesting finding because the intervention did not involve teaching any strategies to explicitly challenge or control unhelpful or upsetting thoughts directly; it only encouraged caregivers to generate more positive thoughts. This highlights this type of intervention may work by helping caregivers be more flexible in their thinking habits, which may prevent caregivers from getting stuck in depressive thoughts patterns. A final important strength of this study was that it was delivered by psychology paraprofessionals, indicating that it may be easier to disseminate more broadly due to the relative lower-intensity training necessary to adequately deliver the treatment.

This study has some important limitations, and will need to be replicated in a larger sample with caregivers with higher ranges of depression symptoms, and a follow-up period, to test if the findings can be replicated. However, it presents an exciting new direction for caregiver support interventions.

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