Depression and Anxiety Among Partner and Offspring Carers of People With Dementia: A Systematic Review

Depression and Anxiety Among Partner and Offspring Carers of People With Dementia: A Systematic... Abstract Background and Objectives Family carers of people with dementia (PWD) experience high rates of depression and anxiety. However, the factors that are associated with these mental health concerns among family carers are not well understood. The purpose of this review was to identify factors that are associated with depression and anxiety in family carers of PWD. Research Design and Methods A systematic review was conducted of studies that examined depressive or anxiety symptoms among family caregivers of community-dwelling older adults with dementia. Twenty-six studies met inclusion criteria and were included in the review. Results Depressive and anxiety symptoms were related to demographic factors, dementia characteristics, carer psychological and social factors, and dyadic relationship factors. Some prominent factors were consistently associated with depressive symptoms across studies. Female carers and adult–child carers, rather than spousal carers, were more likely to experience depressive symptoms. Carers’ coping strategies and activity restriction were also found to be strongly related to depressive symptoms. Severity of dementia-related problematic behaviors was related to carers’ depression and anxiety symptoms. In addition, relationship type and quality were important factors associated with depressive symptoms. Discussion and Implications Several important risk factors for carer depression were highlighted in this review. However, a lack of measurement precision and a reliance on cross-sectional studies limits our understanding of exactly how depression and anxiety progress during the caregiving experience. The implications for prevention and intervention programs for depression and anxiety are discussed, as well as suggestions for future research to improve the quality of research in this area. Systematic review, Caregiving-informal, Depression, Dementia Family carers of people with dementia (PWD) are at greater risk of developing depression and anxiety compared with other carers and people in the general community (D’Aoust, Brewster, & Rowe, 2015; Etters, Goodall, & Harrison, 2008; Fonareva & Oken, 2014; Joling et al., 2010). For example, up to 80% of dementia family carers experience depression, compared with 6%–9% in the general population of adults over the age of 55 (Schoenmakers, Buntinx, & Delepeleire, 2010). The experience of chronic stress and psychological morbidity not only results in negative consequences for the carer, but can compromise the quality of care the carer is able to provide for the PWD (Etters et al., 2008; Fonareva & Oken, 2014; Leach, Francis, & Ziaian, 2014) and contributes to the development of negative feelings toward the PWD (Michon, Weber, Rudhard-Thomazic, & Giannakopoulos, 2005). Reducing the distress and psychological morbidity experienced by family carers of PWD is necessary to enable the family carers to continue to provide care within the home (Joling et al., 2010). Most research that has examined dementia family caregivers’ mental health and well-being has focused on stress and has sought to identify factors that contribute to caregivers’ stress and burden (e.g., Etters et al., 2008; Thies & Bleiler, 2013). As such, the risk factors for chronic stress and burden associated with of the role of being a family carer for a PWD have been well documented (Etters et al., 2008; Thies & Bleiler, 2013). However, depression and anxiety are different from stress and are likely to have different risk factors. Although depression and anxiety are highly prevalent among dementia family caregivers, less research has examined the factors that may contribute to the development of these conditions. Shua-Haim, Haim, Shi, Kuo, and Smith (2001) examined risk factors for depression among Alzheimer caregivers and found that care recipient characteristics, such as depression, a lower score on the mini mental status examination (MMSE), greater dependency and hallucinations were risk factors for caregivers’ depression (Shua-Haim et al., 2001). Other studies have examined contextual, psychological, and relationship risk factors for caregivers’ depression or anxiety. Some of the psychological factors that have been examined in relation to caregivers’ depression or anxiety include caregiver burden, coping strategies, self-efficacy, and feelings of guilt (Epstein-Lubow, Davis, Miller, & Tremont, 2008; Mausbach et al., 2012; Romero-Moreno et al., 2014). Although these papers provide some understanding of the factors associated with depression and anxiety among family carers of PWD, there has been no synthesis of the evidence on this important topic. Previous systematic reviews have investigated the prevalence of depressive and anxiety disorders for carers of PWD (Cooper, Balamurali, & Livingston, 2007; Cuijpers, 2005). However, research is needed to better understand the factors associated with depression and anxiety for carers of PWD and to know that the outcome variables are adequately evaluating depression and anxiety. The novel aspect of this review is that it examined what factors have been specifically associated with depression and anxiety among dementia caregivers and determined the current level of evidence for each of these factors. More specifically, this is the first systematic review to investigate the factors that are associated with depression and anxiety among family carers of PWD, including the factors that may contribute to, and exacerbate the development these conditions. As there have been no previous reviews on this topic, this review focused on immediate family carers because closer relationships are associated with increased carer burden (Etters et al., 2008). Therefore, the experience of depression and anxiety is also likely to be different for immediate family carers compared with “other” carers (e.g., grandchildren, siblings, and friends). The findings from this review will provide directions for further research and ultimately the design of new programs to prevent and treat depression and anxiety among family caregivers. Methods This review was informed by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff, & Altman, 2010). Search Strategy A search of four electronic databases (PsycInfo, Web of Science, MEDLINE, and CINAHL) was conducted in May 2017. The following search terms were used: (a) carer, caregiver, care giver, caring; (b) dementia or Alzheimer; and (c) depression, anxiety, or anxious. The complete search strategy is detailed in Supplementary material. The search was limited to studies published since 2000, as these reflect current research that is appropriate to inform current practice. The search was also limited to English language publications. Reference lists of included papers were searched for additional articles. Eligibility Criteria Following removal of duplicates, studies were screened for suitability via their titles and abstracts in Covidence© (Authors 1 and 2). Included papers focused specifically on immediate family (offspring and spouse/partner/de facto) carers of PWD because they usually have closest contact with the person with dementia and are more likely to be primary caregivers. It was also expected that closer familial relationships might be associated with increased caregiver burden and different experiences of anxiety and depression. Included papers also focused specifically on PWD who were community-dwelling. Additional inclusion criteria were that the study used a psychometrically sound measure of depression and anxiety as the outcome variable, and involved quantitative or qualitative methodologies. The term “Family caregivers” was not included in the search terms as this led to many of the relevant papers being excluded. Papers that were excluded were those that were opinion-pieces, editorials, reviews, books, dissertations, abstracts only, study protocols, or intervention or treatment/experimental studies, did not focus on participants who were current family carers of PWD (e.g., those carers who were no longer providing primary care for the PWD because the PWD had transitioned into an aged care facility or passed away, professional/staff carers, or carers of people who did not have dementia), did not include a specific focus on depression or anxiety (e.g., having a focus on mental health or carer burden), and did not include a psychometrically sound measure of depression and anxiety as the outcome variable. Following initial screening, the full-text articles were examined to determine eligibility for inclusion in the systematic review. Studies were read in their entirety to determine whether they sufficiently investigated the search terms. Any conflicts that occurred were resolved by a third reviewer (Author 3). Data Extraction Data from the studies were manually collated into matrices in Microsoft Excel to enable a comparison of the studies’ aims, samples, measures of depression and anxiety, methodologies, and results. Data extraction was completed by two reviewers (Authors 1 and 2) independently. Data Analysis Data from the quantitative studies were not able to be synthesized using a meta-analysis due to the heterogeneity of the methodologies adopted by the studies. Instead, the key findings for the included studies were appraised and summarized in a narrative synthesis. Results Study Selection The initial search revealed 8,581 records. After the removal of duplicates, 5,227 studies were screened by title and abstract. A total of 127 studies were read as full-text after the removal of 5,099 studies considered ineligible. The final sample was formed by 26 studies that were considered to meet the inclusion criteria. Figure 1 illustrates the screening process. Details of the included studies, their design, methodology, depression and/or anxiety measures used, and main findings are presented in Table 1. Table 1. Summary of Included Studies in the Systematic Review Author (year) country Aims Sample characteristics Study methodology Results Adams and colleagues (2002) USA To investigate similarities and differences in coping across four ethnic groups. n = 202 spousal carers. Carer gender: 67.3% females Carer M age: 67.4–71.9 Design: Cross-sectional. Outcome measure: Older Adult Health and Mood Questionnaire (OAHMQ) Analysis: Multivariate analysis of variance and chi-square. A greater percentage of Mexican American carers reported clinically significantly depressive symptoms, followed by Anglo American carers and African American carers. Female carers were more likely to report depressive symptoms compared with male carers. Beeson and colleagues (2000) USA To examine relationships between depression, relationship quality, and distance felt due to caregiving. n = 242 spousal or daughter carers. Carer gender: 65.0% females. Carer M age: 72.0 for husbands; 70.0 for wives; 52.0 for daughters. PWD M age: 74. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Significant positive correlations were found between depressive symptoms and relational deprivation, quality of the past relationship, and quality of the current relationship. Braun and colleagues (2010) Switzerland To investigate the relationship between depression and marital communication. n = 37 female spousal carers. Carer M age: 67.35. PWD M age: 72.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carer depressive symptoms were significantly negatively associated with care receivers’ positive communication. Chun and colleagues (2007) USA To compare emotional distress among caregivers. n = 171 spousal and adult–child carers. Carer gender: 77.5% females. Carer M age: 53.3–67.7 Design: Cross-sectional. Outcome measure: CES-D State Trait Anxiety Inventory (STAI) Analysis: Path analysis. For White-American carers, care recipient disruptive behaviors were predictive of greater burden, depressive and anxiety symptoms. Carers of parents (compared with carers of spouses) had higher depressive symptoms. Clay and colleagues (2008) USA To investigate changes in social support and psychosocial outcomes in caregivers between ethnic groups. n = 166 spousal and adult–child carers. Carer gender: 69.1% females. Carer M age: 55.7 for African American; 63.4 for White. PWD M age: 74.9 for African American; 73.2 for White Design: Longitudinal. Outcome measure: CES-D Analysis: Linear random effects regression models. White carers reported significantly higher levels of depressive symptoms compared with African American carers across the 5 years. Satisfaction with support and socioeconomic status were significant predictors of depressive symptoms. Epstein-Lubow and colleagues (2008) USA To examine the relationship between burden and depression. n = 33 spousal and adult–child carers. Carer gender: 79.0% females. Carer M age: 60.7–65.5. PWD M age: 75.6. Design: Longitudinal. Outcome measure: Geriatric Depression Scale (GDS) Analysis: Pearson’s correlations and hierarchical regressions. Baseline depressive symptoms and persisting burden were predictive of depressive symptoms at Time 3. Fauth and colleagues (2012) USA To understand associations between relationship closeness and caregiver psychological well-being. n = 234 spousal and adult–child carers. Carer gender: 76.07% females. Carer M age: 69.47. PWD M age: 82.0. Design: Longitudinal. Outcome measure: Beck Depression Inventory (BDI) Analysis: Linear mixed models. Carers who reported higher levels of closeness at baseline reported significantly lower depressive symptoms at baseline. Closeness was not related to depressive symptoms over time and closeness change was not related to rate of change in depressive symptoms. Gallant and Connell (2003) USA To examine the relationship between health behaviors, neuroticism, and depressive symptoms. n = 233 spousal carers. Carer gender: 53.0% females. Carer M age: 68.0 Design: Cross-sectional. Outcome measure: CES-D Analysis: Path analysis. Higher levels of neuroticism were significantly related to higher levels of depressive symptoms. Hayslip and colleagues (2008) USA To determine what factors predict depressed mood for caregivers. n = 42 spousal and adult–child carers. Carer gender: 81.0% females. Carer M age: 55.0. Design: Cross-sectional. Outcome measure: GDS Analysis: Hierarchical regressions. Extraversion and anxiety about ageing uniquely predicted depressed mood. Huang (2004) Taiwan To examine the relationships among demographic factors, situational factors, and coping on health outcomes of female caregivers. n = 103 female spousal and daughter carers. Carer M age: 55.70. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations and multiple regression. Avoidance coping mediated the relationship between the care recipients’ behavioral problems and carer depressive symptoms. Joling and colleagues (2015) The Netherlands To identify significant predictors of depression and anxiety disorders in caregivers. n = 181 spousal carers. Carer gender: 69.6% females. Carer M age: 70.6. PWD M age: 74.4. Design: Longitudinal. Outcome measure: Mini-International Neuropsychiatric Interview (MINI) Analysis: Multivariate regression. Sub-threshold depressive symptoms predicted incidence of a depressive or anxiety disorder. Luchsinger and colleagues (2015) USA To examine the cross-sectional correlates of caregiver depressive symptoms. n = 139 spousal and adult–child carers. Carer gender: 85.7% females. Carer M age: 59.3. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations. There were no differences between spousal and adult–child carers in the depressive symptoms reported. Mausbach and colleagues (2006) USA To test associations between patient problem behaviors, escape-avoidance coping, and depressive symptoms. n = 95 spousal carers. Carer gender: 72.0% female. Carer M age: 72.7. Design: Cross-sectional. Outcome measure: Brief Symptom Inventory (BSI) Analysis: Regressions and Sobel test. Escape-avoidance coping significantly mediated the relationship between patient problem behaviors and depressive symptoms. Mausbach and colleagues (2008) USA To test whether activity restriction mediates the relationship between being a carer and depressive symptoms. n = 16 spousal Alzheimer carers. Carer gender: 76.0% female. Carer M age: 68.1. Design: Cross-sectional. Outcome measure: CES-D Analysis: Regressions and Sobel test. Activity restriction was a significant predictor of depressive symptoms, but caregiving status was not. The Sobel test of the indirect effect was significant. Mausbach and colleagues (2007) USA To evaluate the impact of personal mastery and caregiving stress on depressive symptoms. n = 130 spousal Alzheimer carers. Carer gender: 71.0% female. Carer M age: 72.8. Design: Longitudinal. Outcome measure: Hamilton Depression Rating Scale (HAM-D) Analysis: Linear mixed-effects regression models. Increases in mastery resulted in decreases in depressive symptoms. When mastery was low there was a significant relationship between overload and depressive symptoms. Mausbach and colleagues (2012) USA To evaluate a model to explain how stress is associated with depressive symptoms. n = 126 spousal Alzheimer carers. Carer gender: 70.6% females. Carer M age: 74.2. Design: Cross-sectional. Outcome measure: CES-D Analysis: Bivariate correlations and multiple regression. Decreased personal mastery and self-efficacy were associated with increased depressive symptoms. Increased avoidance coping and activity restriction were associated with increased depressive symptoms. Greater role overload was associated with greater depressive symptoms. McCallum and colleagues (2007) USA To compare caregiver mental health outcomes between African American and White caregivers. n = 70 spousal and daughter carers. Carer M age: ranged from 60.7 to 65.4. Design: Cross-sectional. Outcome measure: CES-D Analysis: T-tests. There were no significant differences in depressive symptoms on the basis of ethnicity. Morano (2003) USA To investigate the relationship between coping and psychological wellbeing. n = 204 spousal and adult–child carers. Carer gender: 71.0% females. Carer M age: 64.0. PWD M age: 79.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Least squares multiple regression. Appraisal of burden mediated the effects of the problematic behavior on depressive symptoms. Emotion-focused coping moderated the effect of problematic behavior on depressive symptoms. O’Rourke and colleagues (2010) Canada To examine whether resilience predicts depressive symptoms. n= 105 spousal carers. Carer gender: 55.2% females. Carer M age: 69.59. Design: Longitudinal. Outcome measure: CES-D Analysis: Multilevel modeling. Younger age of caregivers and low level of educational attainments were significant predictors of increased Time 2 depressive symptoms. Younger caregivers whose spouses had had their diagnoses for longer periods reported significantly more depressive symptoms. Symptom severity and time since patient diagnosis were significantly associated with change in depressive symptoms between time points. Higher levels of challenge (the belief that challenges provide opportunities to increase skills and self-knowledge) and perceived control predicted lower levels of depressive symptoms at Time 2. Pioli (2010) USA To test whether mastery moderates the impact of stressors on depressive and anxious symptoms. n = 200 spousal carers. Carer gender: 61.5% females. Carer M age: 72.9. Design: Cross-sectional. Outcome measure: Hopkins Symptom Checklist (HSCL) Analysis: Multivariate linear regressions. Caregiving mastery was a significant moderator for the relationship between both subjective demands and role captivity on depressive symptoms. Caregiving mastery was a significant moderator of the relationship between both role overload and role captivity on anxiety symptoms. Pöysti and colleagues (2012) Finland To compare the burden of male and female spousal caregivers. n= 335 spousal carers. Carer gender: 61.8% females. Carer M age: 77.8 PWD M age: 77.2 Design: Cross-sectional. Outcome measure: GDS Analysis: Mann–Whitney test. Female carers reported greater depressive symptoms compared with male carers. Rankin and colleagues (2001) USA To investigate the effect of marital functioning on caregivers mental health. n = 96 spousal carers. Carer gender: 53.0% females. Carer M age: 69.0. PWD M age: 70.9. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations, χ2 tests, t test, and path analyses. Carers with depression reported lower levels of marital cohesion and family satisfaction compared with those carers without depression. Romero-Moreno and colleagues (2014) Spain To examine the moderator role of guilt on the effect of leisure activities on caregivers’ depressive symptoms. n= 351 spousal and adult–child carers. Carer gender: 78.63% females. Carer M age: 60.19. PWD M age: 78.76. Design: Cross-sectional. Outcome Measure: CES-D Analysis: Hierarchical regressions. Frequency of behavioral problems and leisure activities, hours of caring, and guilt had a significant effect on depressive symptoms for daughters. Guilt was a significant moderator of the relationship between frequency of leisure activities and depressive symptoms for daughters. Rosness and colleagues (2011) Norway To investigate correlates of depressive symptoms for carers. n= 49 spousal or de facto carers. Carer Gender: 65.7% females for carers; 81.8% females for non- carers. Carer M age: 60.3. PWD M age: 60.1. Design: Cross-sectional. Outcome measure: GDS Analysis: Multiple regression. Being married and having children, having a care recipient with a cardiovascular disease or no domiciliary nursing care were significantly associated with higher depressive symptoms for the carers. Williams (2011) USA To identify risk factors within marital relationships for caregiver depression. n= 16 spousal carers. Carer gender: 68.7% females. Carer M age: 77.38. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carers who reported more burden also reported greater depressive symptoms. Wojtyna and Popiołek (2012) Poland To examine the relationships between psychophysical functioning of the care recipient and the psychological costs for the caregiver. n= 104 spousal or de facto carers. Carer gender: 58.65% females. Carer M age: 70.31. Design: Cross-sectional. Outcome measure: BDI Analysis: Pearson’s correlations, and multiple regression. Time of daily care (hours/day) and level of independence of the care recipient were significantly associated with depressive symptoms. Depression increased with a growing sense of loss, an extended time of daily care and a lower level of independence of the patient. Author (year) country Aims Sample characteristics Study methodology Results Adams and colleagues (2002) USA To investigate similarities and differences in coping across four ethnic groups. n = 202 spousal carers. Carer gender: 67.3% females Carer M age: 67.4–71.9 Design: Cross-sectional. Outcome measure: Older Adult Health and Mood Questionnaire (OAHMQ) Analysis: Multivariate analysis of variance and chi-square. A greater percentage of Mexican American carers reported clinically significantly depressive symptoms, followed by Anglo American carers and African American carers. Female carers were more likely to report depressive symptoms compared with male carers. Beeson and colleagues (2000) USA To examine relationships between depression, relationship quality, and distance felt due to caregiving. n = 242 spousal or daughter carers. Carer gender: 65.0% females. Carer M age: 72.0 for husbands; 70.0 for wives; 52.0 for daughters. PWD M age: 74. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Significant positive correlations were found between depressive symptoms and relational deprivation, quality of the past relationship, and quality of the current relationship. Braun and colleagues (2010) Switzerland To investigate the relationship between depression and marital communication. n = 37 female spousal carers. Carer M age: 67.35. PWD M age: 72.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carer depressive symptoms were significantly negatively associated with care receivers’ positive communication. Chun and colleagues (2007) USA To compare emotional distress among caregivers. n = 171 spousal and adult–child carers. Carer gender: 77.5% females. Carer M age: 53.3–67.7 Design: Cross-sectional. Outcome measure: CES-D State Trait Anxiety Inventory (STAI) Analysis: Path analysis. For White-American carers, care recipient disruptive behaviors were predictive of greater burden, depressive and anxiety symptoms. Carers of parents (compared with carers of spouses) had higher depressive symptoms. Clay and colleagues (2008) USA To investigate changes in social support and psychosocial outcomes in caregivers between ethnic groups. n = 166 spousal and adult–child carers. Carer gender: 69.1% females. Carer M age: 55.7 for African American; 63.4 for White. PWD M age: 74.9 for African American; 73.2 for White Design: Longitudinal. Outcome measure: CES-D Analysis: Linear random effects regression models. White carers reported significantly higher levels of depressive symptoms compared with African American carers across the 5 years. Satisfaction with support and socioeconomic status were significant predictors of depressive symptoms. Epstein-Lubow and colleagues (2008) USA To examine the relationship between burden and depression. n = 33 spousal and adult–child carers. Carer gender: 79.0% females. Carer M age: 60.7–65.5. PWD M age: 75.6. Design: Longitudinal. Outcome measure: Geriatric Depression Scale (GDS) Analysis: Pearson’s correlations and hierarchical regressions. Baseline depressive symptoms and persisting burden were predictive of depressive symptoms at Time 3. Fauth and colleagues (2012) USA To understand associations between relationship closeness and caregiver psychological well-being. n = 234 spousal and adult–child carers. Carer gender: 76.07% females. Carer M age: 69.47. PWD M age: 82.0. Design: Longitudinal. Outcome measure: Beck Depression Inventory (BDI) Analysis: Linear mixed models. Carers who reported higher levels of closeness at baseline reported significantly lower depressive symptoms at baseline. Closeness was not related to depressive symptoms over time and closeness change was not related to rate of change in depressive symptoms. Gallant and Connell (2003) USA To examine the relationship between health behaviors, neuroticism, and depressive symptoms. n = 233 spousal carers. Carer gender: 53.0% females. Carer M age: 68.0 Design: Cross-sectional. Outcome measure: CES-D Analysis: Path analysis. Higher levels of neuroticism were significantly related to higher levels of depressive symptoms. Hayslip and colleagues (2008) USA To determine what factors predict depressed mood for caregivers. n = 42 spousal and adult–child carers. Carer gender: 81.0% females. Carer M age: 55.0. Design: Cross-sectional. Outcome measure: GDS Analysis: Hierarchical regressions. Extraversion and anxiety about ageing uniquely predicted depressed mood. Huang (2004) Taiwan To examine the relationships among demographic factors, situational factors, and coping on health outcomes of female caregivers. n = 103 female spousal and daughter carers. Carer M age: 55.70. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations and multiple regression. Avoidance coping mediated the relationship between the care recipients’ behavioral problems and carer depressive symptoms. Joling and colleagues (2015) The Netherlands To identify significant predictors of depression and anxiety disorders in caregivers. n = 181 spousal carers. Carer gender: 69.6% females. Carer M age: 70.6. PWD M age: 74.4. Design: Longitudinal. Outcome measure: Mini-International Neuropsychiatric Interview (MINI) Analysis: Multivariate regression. Sub-threshold depressive symptoms predicted incidence of a depressive or anxiety disorder. Luchsinger and colleagues (2015) USA To examine the cross-sectional correlates of caregiver depressive symptoms. n = 139 spousal and adult–child carers. Carer gender: 85.7% females. Carer M age: 59.3. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations. There were no differences between spousal and adult–child carers in the depressive symptoms reported. Mausbach and colleagues (2006) USA To test associations between patient problem behaviors, escape-avoidance coping, and depressive symptoms. n = 95 spousal carers. Carer gender: 72.0% female. Carer M age: 72.7. Design: Cross-sectional. Outcome measure: Brief Symptom Inventory (BSI) Analysis: Regressions and Sobel test. Escape-avoidance coping significantly mediated the relationship between patient problem behaviors and depressive symptoms. Mausbach and colleagues (2008) USA To test whether activity restriction mediates the relationship between being a carer and depressive symptoms. n = 16 spousal Alzheimer carers. Carer gender: 76.0% female. Carer M age: 68.1. Design: Cross-sectional. Outcome measure: CES-D Analysis: Regressions and Sobel test. Activity restriction was a significant predictor of depressive symptoms, but caregiving status was not. The Sobel test of the indirect effect was significant. Mausbach and colleagues (2007) USA To evaluate the impact of personal mastery and caregiving stress on depressive symptoms. n = 130 spousal Alzheimer carers. Carer gender: 71.0% female. Carer M age: 72.8. Design: Longitudinal. Outcome measure: Hamilton Depression Rating Scale (HAM-D) Analysis: Linear mixed-effects regression models. Increases in mastery resulted in decreases in depressive symptoms. When mastery was low there was a significant relationship between overload and depressive symptoms. Mausbach and colleagues (2012) USA To evaluate a model to explain how stress is associated with depressive symptoms. n = 126 spousal Alzheimer carers. Carer gender: 70.6% females. Carer M age: 74.2. Design: Cross-sectional. Outcome measure: CES-D Analysis: Bivariate correlations and multiple regression. Decreased personal mastery and self-efficacy were associated with increased depressive symptoms. Increased avoidance coping and activity restriction were associated with increased depressive symptoms. Greater role overload was associated with greater depressive symptoms. McCallum and colleagues (2007) USA To compare caregiver mental health outcomes between African American and White caregivers. n = 70 spousal and daughter carers. Carer M age: ranged from 60.7 to 65.4. Design: Cross-sectional. Outcome measure: CES-D Analysis: T-tests. There were no significant differences in depressive symptoms on the basis of ethnicity. Morano (2003) USA To investigate the relationship between coping and psychological wellbeing. n = 204 spousal and adult–child carers. Carer gender: 71.0% females. Carer M age: 64.0. PWD M age: 79.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Least squares multiple regression. Appraisal of burden mediated the effects of the problematic behavior on depressive symptoms. Emotion-focused coping moderated the effect of problematic behavior on depressive symptoms. O’Rourke and colleagues (2010) Canada To examine whether resilience predicts depressive symptoms. n= 105 spousal carers. Carer gender: 55.2% females. Carer M age: 69.59. Design: Longitudinal. Outcome measure: CES-D Analysis: Multilevel modeling. Younger age of caregivers and low level of educational attainments were significant predictors of increased Time 2 depressive symptoms. Younger caregivers whose spouses had had their diagnoses for longer periods reported significantly more depressive symptoms. Symptom severity and time since patient diagnosis were significantly associated with change in depressive symptoms between time points. Higher levels of challenge (the belief that challenges provide opportunities to increase skills and self-knowledge) and perceived control predicted lower levels of depressive symptoms at Time 2. Pioli (2010) USA To test whether mastery moderates the impact of stressors on depressive and anxious symptoms. n = 200 spousal carers. Carer gender: 61.5% females. Carer M age: 72.9. Design: Cross-sectional. Outcome measure: Hopkins Symptom Checklist (HSCL) Analysis: Multivariate linear regressions. Caregiving mastery was a significant moderator for the relationship between both subjective demands and role captivity on depressive symptoms. Caregiving mastery was a significant moderator of the relationship between both role overload and role captivity on anxiety symptoms. Pöysti and colleagues (2012) Finland To compare the burden of male and female spousal caregivers. n= 335 spousal carers. Carer gender: 61.8% females. Carer M age: 77.8 PWD M age: 77.2 Design: Cross-sectional. Outcome measure: GDS Analysis: Mann–Whitney test. Female carers reported greater depressive symptoms compared with male carers. Rankin and colleagues (2001) USA To investigate the effect of marital functioning on caregivers mental health. n = 96 spousal carers. Carer gender: 53.0% females. Carer M age: 69.0. PWD M age: 70.9. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations, χ2 tests, t test, and path analyses. Carers with depression reported lower levels of marital cohesion and family satisfaction compared with those carers without depression. Romero-Moreno and colleagues (2014) Spain To examine the moderator role of guilt on the effect of leisure activities on caregivers’ depressive symptoms. n= 351 spousal and adult–child carers. Carer gender: 78.63% females. Carer M age: 60.19. PWD M age: 78.76. Design: Cross-sectional. Outcome Measure: CES-D Analysis: Hierarchical regressions. Frequency of behavioral problems and leisure activities, hours of caring, and guilt had a significant effect on depressive symptoms for daughters. Guilt was a significant moderator of the relationship between frequency of leisure activities and depressive symptoms for daughters. Rosness and colleagues (2011) Norway To investigate correlates of depressive symptoms for carers. n= 49 spousal or de facto carers. Carer Gender: 65.7% females for carers; 81.8% females for non- carers. Carer M age: 60.3. PWD M age: 60.1. Design: Cross-sectional. Outcome measure: GDS Analysis: Multiple regression. Being married and having children, having a care recipient with a cardiovascular disease or no domiciliary nursing care were significantly associated with higher depressive symptoms for the carers. Williams (2011) USA To identify risk factors within marital relationships for caregiver depression. n= 16 spousal carers. Carer gender: 68.7% females. Carer M age: 77.38. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carers who reported more burden also reported greater depressive symptoms. Wojtyna and Popiołek (2012) Poland To examine the relationships between psychophysical functioning of the care recipient and the psychological costs for the caregiver. n= 104 spousal or de facto carers. Carer gender: 58.65% females. Carer M age: 70.31. Design: Cross-sectional. Outcome measure: BDI Analysis: Pearson’s correlations, and multiple regression. Time of daily care (hours/day) and level of independence of the care recipient were significantly associated with depressive symptoms. Depression increased with a growing sense of loss, an extended time of daily care and a lower level of independence of the patient. View Large Table 1. Summary of Included Studies in the Systematic Review Author (year) country Aims Sample characteristics Study methodology Results Adams and colleagues (2002) USA To investigate similarities and differences in coping across four ethnic groups. n = 202 spousal carers. Carer gender: 67.3% females Carer M age: 67.4–71.9 Design: Cross-sectional. Outcome measure: Older Adult Health and Mood Questionnaire (OAHMQ) Analysis: Multivariate analysis of variance and chi-square. A greater percentage of Mexican American carers reported clinically significantly depressive symptoms, followed by Anglo American carers and African American carers. Female carers were more likely to report depressive symptoms compared with male carers. Beeson and colleagues (2000) USA To examine relationships between depression, relationship quality, and distance felt due to caregiving. n = 242 spousal or daughter carers. Carer gender: 65.0% females. Carer M age: 72.0 for husbands; 70.0 for wives; 52.0 for daughters. PWD M age: 74. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Significant positive correlations were found between depressive symptoms and relational deprivation, quality of the past relationship, and quality of the current relationship. Braun and colleagues (2010) Switzerland To investigate the relationship between depression and marital communication. n = 37 female spousal carers. Carer M age: 67.35. PWD M age: 72.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carer depressive symptoms were significantly negatively associated with care receivers’ positive communication. Chun and colleagues (2007) USA To compare emotional distress among caregivers. n = 171 spousal and adult–child carers. Carer gender: 77.5% females. Carer M age: 53.3–67.7 Design: Cross-sectional. Outcome measure: CES-D State Trait Anxiety Inventory (STAI) Analysis: Path analysis. For White-American carers, care recipient disruptive behaviors were predictive of greater burden, depressive and anxiety symptoms. Carers of parents (compared with carers of spouses) had higher depressive symptoms. Clay and colleagues (2008) USA To investigate changes in social support and psychosocial outcomes in caregivers between ethnic groups. n = 166 spousal and adult–child carers. Carer gender: 69.1% females. Carer M age: 55.7 for African American; 63.4 for White. PWD M age: 74.9 for African American; 73.2 for White Design: Longitudinal. Outcome measure: CES-D Analysis: Linear random effects regression models. White carers reported significantly higher levels of depressive symptoms compared with African American carers across the 5 years. Satisfaction with support and socioeconomic status were significant predictors of depressive symptoms. Epstein-Lubow and colleagues (2008) USA To examine the relationship between burden and depression. n = 33 spousal and adult–child carers. Carer gender: 79.0% females. Carer M age: 60.7–65.5. PWD M age: 75.6. Design: Longitudinal. Outcome measure: Geriatric Depression Scale (GDS) Analysis: Pearson’s correlations and hierarchical regressions. Baseline depressive symptoms and persisting burden were predictive of depressive symptoms at Time 3. Fauth and colleagues (2012) USA To understand associations between relationship closeness and caregiver psychological well-being. n = 234 spousal and adult–child carers. Carer gender: 76.07% females. Carer M age: 69.47. PWD M age: 82.0. Design: Longitudinal. Outcome measure: Beck Depression Inventory (BDI) Analysis: Linear mixed models. Carers who reported higher levels of closeness at baseline reported significantly lower depressive symptoms at baseline. Closeness was not related to depressive symptoms over time and closeness change was not related to rate of change in depressive symptoms. Gallant and Connell (2003) USA To examine the relationship between health behaviors, neuroticism, and depressive symptoms. n = 233 spousal carers. Carer gender: 53.0% females. Carer M age: 68.0 Design: Cross-sectional. Outcome measure: CES-D Analysis: Path analysis. Higher levels of neuroticism were significantly related to higher levels of depressive symptoms. Hayslip and colleagues (2008) USA To determine what factors predict depressed mood for caregivers. n = 42 spousal and adult–child carers. Carer gender: 81.0% females. Carer M age: 55.0. Design: Cross-sectional. Outcome measure: GDS Analysis: Hierarchical regressions. Extraversion and anxiety about ageing uniquely predicted depressed mood. Huang (2004) Taiwan To examine the relationships among demographic factors, situational factors, and coping on health outcomes of female caregivers. n = 103 female spousal and daughter carers. Carer M age: 55.70. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations and multiple regression. Avoidance coping mediated the relationship between the care recipients’ behavioral problems and carer depressive symptoms. Joling and colleagues (2015) The Netherlands To identify significant predictors of depression and anxiety disorders in caregivers. n = 181 spousal carers. Carer gender: 69.6% females. Carer M age: 70.6. PWD M age: 74.4. Design: Longitudinal. Outcome measure: Mini-International Neuropsychiatric Interview (MINI) Analysis: Multivariate regression. Sub-threshold depressive symptoms predicted incidence of a depressive or anxiety disorder. Luchsinger and colleagues (2015) USA To examine the cross-sectional correlates of caregiver depressive symptoms. n = 139 spousal and adult–child carers. Carer gender: 85.7% females. Carer M age: 59.3. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations. There were no differences between spousal and adult–child carers in the depressive symptoms reported. Mausbach and colleagues (2006) USA To test associations between patient problem behaviors, escape-avoidance coping, and depressive symptoms. n = 95 spousal carers. Carer gender: 72.0% female. Carer M age: 72.7. Design: Cross-sectional. Outcome measure: Brief Symptom Inventory (BSI) Analysis: Regressions and Sobel test. Escape-avoidance coping significantly mediated the relationship between patient problem behaviors and depressive symptoms. Mausbach and colleagues (2008) USA To test whether activity restriction mediates the relationship between being a carer and depressive symptoms. n = 16 spousal Alzheimer carers. Carer gender: 76.0% female. Carer M age: 68.1. Design: Cross-sectional. Outcome measure: CES-D Analysis: Regressions and Sobel test. Activity restriction was a significant predictor of depressive symptoms, but caregiving status was not. The Sobel test of the indirect effect was significant. Mausbach and colleagues (2007) USA To evaluate the impact of personal mastery and caregiving stress on depressive symptoms. n = 130 spousal Alzheimer carers. Carer gender: 71.0% female. Carer M age: 72.8. Design: Longitudinal. Outcome measure: Hamilton Depression Rating Scale (HAM-D) Analysis: Linear mixed-effects regression models. Increases in mastery resulted in decreases in depressive symptoms. When mastery was low there was a significant relationship between overload and depressive symptoms. Mausbach and colleagues (2012) USA To evaluate a model to explain how stress is associated with depressive symptoms. n = 126 spousal Alzheimer carers. Carer gender: 70.6% females. Carer M age: 74.2. Design: Cross-sectional. Outcome measure: CES-D Analysis: Bivariate correlations and multiple regression. Decreased personal mastery and self-efficacy were associated with increased depressive symptoms. Increased avoidance coping and activity restriction were associated with increased depressive symptoms. Greater role overload was associated with greater depressive symptoms. McCallum and colleagues (2007) USA To compare caregiver mental health outcomes between African American and White caregivers. n = 70 spousal and daughter carers. Carer M age: ranged from 60.7 to 65.4. Design: Cross-sectional. Outcome measure: CES-D Analysis: T-tests. There were no significant differences in depressive symptoms on the basis of ethnicity. Morano (2003) USA To investigate the relationship between coping and psychological wellbeing. n = 204 spousal and adult–child carers. Carer gender: 71.0% females. Carer M age: 64.0. PWD M age: 79.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Least squares multiple regression. Appraisal of burden mediated the effects of the problematic behavior on depressive symptoms. Emotion-focused coping moderated the effect of problematic behavior on depressive symptoms. O’Rourke and colleagues (2010) Canada To examine whether resilience predicts depressive symptoms. n= 105 spousal carers. Carer gender: 55.2% females. Carer M age: 69.59. Design: Longitudinal. Outcome measure: CES-D Analysis: Multilevel modeling. Younger age of caregivers and low level of educational attainments were significant predictors of increased Time 2 depressive symptoms. Younger caregivers whose spouses had had their diagnoses for longer periods reported significantly more depressive symptoms. Symptom severity and time since patient diagnosis were significantly associated with change in depressive symptoms between time points. Higher levels of challenge (the belief that challenges provide opportunities to increase skills and self-knowledge) and perceived control predicted lower levels of depressive symptoms at Time 2. Pioli (2010) USA To test whether mastery moderates the impact of stressors on depressive and anxious symptoms. n = 200 spousal carers. Carer gender: 61.5% females. Carer M age: 72.9. Design: Cross-sectional. Outcome measure: Hopkins Symptom Checklist (HSCL) Analysis: Multivariate linear regressions. Caregiving mastery was a significant moderator for the relationship between both subjective demands and role captivity on depressive symptoms. Caregiving mastery was a significant moderator of the relationship between both role overload and role captivity on anxiety symptoms. Pöysti and colleagues (2012) Finland To compare the burden of male and female spousal caregivers. n= 335 spousal carers. Carer gender: 61.8% females. Carer M age: 77.8 PWD M age: 77.2 Design: Cross-sectional. Outcome measure: GDS Analysis: Mann–Whitney test. Female carers reported greater depressive symptoms compared with male carers. Rankin and colleagues (2001) USA To investigate the effect of marital functioning on caregivers mental health. n = 96 spousal carers. Carer gender: 53.0% females. Carer M age: 69.0. PWD M age: 70.9. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations, χ2 tests, t test, and path analyses. Carers with depression reported lower levels of marital cohesion and family satisfaction compared with those carers without depression. Romero-Moreno and colleagues (2014) Spain To examine the moderator role of guilt on the effect of leisure activities on caregivers’ depressive symptoms. n= 351 spousal and adult–child carers. Carer gender: 78.63% females. Carer M age: 60.19. PWD M age: 78.76. Design: Cross-sectional. Outcome Measure: CES-D Analysis: Hierarchical regressions. Frequency of behavioral problems and leisure activities, hours of caring, and guilt had a significant effect on depressive symptoms for daughters. Guilt was a significant moderator of the relationship between frequency of leisure activities and depressive symptoms for daughters. Rosness and colleagues (2011) Norway To investigate correlates of depressive symptoms for carers. n= 49 spousal or de facto carers. Carer Gender: 65.7% females for carers; 81.8% females for non- carers. Carer M age: 60.3. PWD M age: 60.1. Design: Cross-sectional. Outcome measure: GDS Analysis: Multiple regression. Being married and having children, having a care recipient with a cardiovascular disease or no domiciliary nursing care were significantly associated with higher depressive symptoms for the carers. Williams (2011) USA To identify risk factors within marital relationships for caregiver depression. n= 16 spousal carers. Carer gender: 68.7% females. Carer M age: 77.38. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carers who reported more burden also reported greater depressive symptoms. Wojtyna and Popiołek (2012) Poland To examine the relationships between psychophysical functioning of the care recipient and the psychological costs for the caregiver. n= 104 spousal or de facto carers. Carer gender: 58.65% females. Carer M age: 70.31. Design: Cross-sectional. Outcome measure: BDI Analysis: Pearson’s correlations, and multiple regression. Time of daily care (hours/day) and level of independence of the care recipient were significantly associated with depressive symptoms. Depression increased with a growing sense of loss, an extended time of daily care and a lower level of independence of the patient. Author (year) country Aims Sample characteristics Study methodology Results Adams and colleagues (2002) USA To investigate similarities and differences in coping across four ethnic groups. n = 202 spousal carers. Carer gender: 67.3% females Carer M age: 67.4–71.9 Design: Cross-sectional. Outcome measure: Older Adult Health and Mood Questionnaire (OAHMQ) Analysis: Multivariate analysis of variance and chi-square. A greater percentage of Mexican American carers reported clinically significantly depressive symptoms, followed by Anglo American carers and African American carers. Female carers were more likely to report depressive symptoms compared with male carers. Beeson and colleagues (2000) USA To examine relationships between depression, relationship quality, and distance felt due to caregiving. n = 242 spousal or daughter carers. Carer gender: 65.0% females. Carer M age: 72.0 for husbands; 70.0 for wives; 52.0 for daughters. PWD M age: 74. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Significant positive correlations were found between depressive symptoms and relational deprivation, quality of the past relationship, and quality of the current relationship. Braun and colleagues (2010) Switzerland To investigate the relationship between depression and marital communication. n = 37 female spousal carers. Carer M age: 67.35. PWD M age: 72.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carer depressive symptoms were significantly negatively associated with care receivers’ positive communication. Chun and colleagues (2007) USA To compare emotional distress among caregivers. n = 171 spousal and adult–child carers. Carer gender: 77.5% females. Carer M age: 53.3–67.7 Design: Cross-sectional. Outcome measure: CES-D State Trait Anxiety Inventory (STAI) Analysis: Path analysis. For White-American carers, care recipient disruptive behaviors were predictive of greater burden, depressive and anxiety symptoms. Carers of parents (compared with carers of spouses) had higher depressive symptoms. Clay and colleagues (2008) USA To investigate changes in social support and psychosocial outcomes in caregivers between ethnic groups. n = 166 spousal and adult–child carers. Carer gender: 69.1% females. Carer M age: 55.7 for African American; 63.4 for White. PWD M age: 74.9 for African American; 73.2 for White Design: Longitudinal. Outcome measure: CES-D Analysis: Linear random effects regression models. White carers reported significantly higher levels of depressive symptoms compared with African American carers across the 5 years. Satisfaction with support and socioeconomic status were significant predictors of depressive symptoms. Epstein-Lubow and colleagues (2008) USA To examine the relationship between burden and depression. n = 33 spousal and adult–child carers. Carer gender: 79.0% females. Carer M age: 60.7–65.5. PWD M age: 75.6. Design: Longitudinal. Outcome measure: Geriatric Depression Scale (GDS) Analysis: Pearson’s correlations and hierarchical regressions. Baseline depressive symptoms and persisting burden were predictive of depressive symptoms at Time 3. Fauth and colleagues (2012) USA To understand associations between relationship closeness and caregiver psychological well-being. n = 234 spousal and adult–child carers. Carer gender: 76.07% females. Carer M age: 69.47. PWD M age: 82.0. Design: Longitudinal. Outcome measure: Beck Depression Inventory (BDI) Analysis: Linear mixed models. Carers who reported higher levels of closeness at baseline reported significantly lower depressive symptoms at baseline. Closeness was not related to depressive symptoms over time and closeness change was not related to rate of change in depressive symptoms. Gallant and Connell (2003) USA To examine the relationship between health behaviors, neuroticism, and depressive symptoms. n = 233 spousal carers. Carer gender: 53.0% females. Carer M age: 68.0 Design: Cross-sectional. Outcome measure: CES-D Analysis: Path analysis. Higher levels of neuroticism were significantly related to higher levels of depressive symptoms. Hayslip and colleagues (2008) USA To determine what factors predict depressed mood for caregivers. n = 42 spousal and adult–child carers. Carer gender: 81.0% females. Carer M age: 55.0. Design: Cross-sectional. Outcome measure: GDS Analysis: Hierarchical regressions. Extraversion and anxiety about ageing uniquely predicted depressed mood. Huang (2004) Taiwan To examine the relationships among demographic factors, situational factors, and coping on health outcomes of female caregivers. n = 103 female spousal and daughter carers. Carer M age: 55.70. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations and multiple regression. Avoidance coping mediated the relationship between the care recipients’ behavioral problems and carer depressive symptoms. Joling and colleagues (2015) The Netherlands To identify significant predictors of depression and anxiety disorders in caregivers. n = 181 spousal carers. Carer gender: 69.6% females. Carer M age: 70.6. PWD M age: 74.4. Design: Longitudinal. Outcome measure: Mini-International Neuropsychiatric Interview (MINI) Analysis: Multivariate regression. Sub-threshold depressive symptoms predicted incidence of a depressive or anxiety disorder. Luchsinger and colleagues (2015) USA To examine the cross-sectional correlates of caregiver depressive symptoms. n = 139 spousal and adult–child carers. Carer gender: 85.7% females. Carer M age: 59.3. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations. There were no differences between spousal and adult–child carers in the depressive symptoms reported. Mausbach and colleagues (2006) USA To test associations between patient problem behaviors, escape-avoidance coping, and depressive symptoms. n = 95 spousal carers. Carer gender: 72.0% female. Carer M age: 72.7. Design: Cross-sectional. Outcome measure: Brief Symptom Inventory (BSI) Analysis: Regressions and Sobel test. Escape-avoidance coping significantly mediated the relationship between patient problem behaviors and depressive symptoms. Mausbach and colleagues (2008) USA To test whether activity restriction mediates the relationship between being a carer and depressive symptoms. n = 16 spousal Alzheimer carers. Carer gender: 76.0% female. Carer M age: 68.1. Design: Cross-sectional. Outcome measure: CES-D Analysis: Regressions and Sobel test. Activity restriction was a significant predictor of depressive symptoms, but caregiving status was not. The Sobel test of the indirect effect was significant. Mausbach and colleagues (2007) USA To evaluate the impact of personal mastery and caregiving stress on depressive symptoms. n = 130 spousal Alzheimer carers. Carer gender: 71.0% female. Carer M age: 72.8. Design: Longitudinal. Outcome measure: Hamilton Depression Rating Scale (HAM-D) Analysis: Linear mixed-effects regression models. Increases in mastery resulted in decreases in depressive symptoms. When mastery was low there was a significant relationship between overload and depressive symptoms. Mausbach and colleagues (2012) USA To evaluate a model to explain how stress is associated with depressive symptoms. n = 126 spousal Alzheimer carers. Carer gender: 70.6% females. Carer M age: 74.2. Design: Cross-sectional. Outcome measure: CES-D Analysis: Bivariate correlations and multiple regression. Decreased personal mastery and self-efficacy were associated with increased depressive symptoms. Increased avoidance coping and activity restriction were associated with increased depressive symptoms. Greater role overload was associated with greater depressive symptoms. McCallum and colleagues (2007) USA To compare caregiver mental health outcomes between African American and White caregivers. n = 70 spousal and daughter carers. Carer M age: ranged from 60.7 to 65.4. Design: Cross-sectional. Outcome measure: CES-D Analysis: T-tests. There were no significant differences in depressive symptoms on the basis of ethnicity. Morano (2003) USA To investigate the relationship between coping and psychological wellbeing. n = 204 spousal and adult–child carers. Carer gender: 71.0% females. Carer M age: 64.0. PWD M age: 79.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Least squares multiple regression. Appraisal of burden mediated the effects of the problematic behavior on depressive symptoms. Emotion-focused coping moderated the effect of problematic behavior on depressive symptoms. O’Rourke and colleagues (2010) Canada To examine whether resilience predicts depressive symptoms. n= 105 spousal carers. Carer gender: 55.2% females. Carer M age: 69.59. Design: Longitudinal. Outcome measure: CES-D Analysis: Multilevel modeling. Younger age of caregivers and low level of educational attainments were significant predictors of increased Time 2 depressive symptoms. Younger caregivers whose spouses had had their diagnoses for longer periods reported significantly more depressive symptoms. Symptom severity and time since patient diagnosis were significantly associated with change in depressive symptoms between time points. Higher levels of challenge (the belief that challenges provide opportunities to increase skills and self-knowledge) and perceived control predicted lower levels of depressive symptoms at Time 2. Pioli (2010) USA To test whether mastery moderates the impact of stressors on depressive and anxious symptoms. n = 200 spousal carers. Carer gender: 61.5% females. Carer M age: 72.9. Design: Cross-sectional. Outcome measure: Hopkins Symptom Checklist (HSCL) Analysis: Multivariate linear regressions. Caregiving mastery was a significant moderator for the relationship between both subjective demands and role captivity on depressive symptoms. Caregiving mastery was a significant moderator of the relationship between both role overload and role captivity on anxiety symptoms. Pöysti and colleagues (2012) Finland To compare the burden of male and female spousal caregivers. n= 335 spousal carers. Carer gender: 61.8% females. Carer M age: 77.8 PWD M age: 77.2 Design: Cross-sectional. Outcome measure: GDS Analysis: Mann–Whitney test. Female carers reported greater depressive symptoms compared with male carers. Rankin and colleagues (2001) USA To investigate the effect of marital functioning on caregivers mental health. n = 96 spousal carers. Carer gender: 53.0% females. Carer M age: 69.0. PWD M age: 70.9. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations, χ2 tests, t test, and path analyses. Carers with depression reported lower levels of marital cohesion and family satisfaction compared with those carers without depression. Romero-Moreno and colleagues (2014) Spain To examine the moderator role of guilt on the effect of leisure activities on caregivers’ depressive symptoms. n= 351 spousal and adult–child carers. Carer gender: 78.63% females. Carer M age: 60.19. PWD M age: 78.76. Design: Cross-sectional. Outcome Measure: CES-D Analysis: Hierarchical regressions. Frequency of behavioral problems and leisure activities, hours of caring, and guilt had a significant effect on depressive symptoms for daughters. Guilt was a significant moderator of the relationship between frequency of leisure activities and depressive symptoms for daughters. Rosness and colleagues (2011) Norway To investigate correlates of depressive symptoms for carers. n= 49 spousal or de facto carers. Carer Gender: 65.7% females for carers; 81.8% females for non- carers. Carer M age: 60.3. PWD M age: 60.1. Design: Cross-sectional. Outcome measure: GDS Analysis: Multiple regression. Being married and having children, having a care recipient with a cardiovascular disease or no domiciliary nursing care were significantly associated with higher depressive symptoms for the carers. Williams (2011) USA To identify risk factors within marital relationships for caregiver depression. n= 16 spousal carers. Carer gender: 68.7% females. Carer M age: 77.38. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carers who reported more burden also reported greater depressive symptoms. Wojtyna and Popiołek (2012) Poland To examine the relationships between psychophysical functioning of the care recipient and the psychological costs for the caregiver. n= 104 spousal or de facto carers. Carer gender: 58.65% females. Carer M age: 70.31. Design: Cross-sectional. Outcome measure: BDI Analysis: Pearson’s correlations, and multiple regression. Time of daily care (hours/day) and level of independence of the care recipient were significantly associated with depressive symptoms. Depression increased with a growing sense of loss, an extended time of daily care and a lower level of independence of the patient. View Large Figure 1. View largeDownload slide Study screening process. Figure 1. View largeDownload slide Study screening process. Study Characteristics All of the 26 studies included in the review were quantitative in design; all but six of the studies were cross-sectional in design. A total of 18 studies were based in the United States; and one, respectively, in Canada, Switzerland, Taiwan, Finland, Spain, Norway, Poland, and the Netherlands. Sample sizes ranged from 16 to 351. Spousal and de facto carers were sampled exclusively in 15 of the studies, with the remaining 11 studies sampling both spousal and adult–child carers. The majority of studies included both female and male carers; three studies focused exclusively on female carers. Eight of the studies sampled specific dementia diagnoses (e.g., Alzheimer’s disease), and the remaining studies included people with any dementia diagnosis. All of the studies included depression as a focus; only three studies included anxiety as a focus. A total of nine scales were used across the included studies to measure depression and anxiety; seven self-report scales were used to measure depressive symptoms. The most consistently used measures of depressive symptoms were the Centre for Epidemiology Scale for Depression in Dementia (Radloff, 1977) and the Geriatric Depression Scale (Sheikh & Yesavage, 1986; Yesavage et al., 1982), which were used in 13 and 6 of the included studies, respectively. Two self-report measures were used to assess anxiety symptoms: the State Trait Anxiety Inventory (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1985) and the Hopkins Symptom Checklist (Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974). A structured diagnostic instrument, specifically the Mini-International Neuropsychiatric Interview (Sheehan et al., 1998), to assess the presence of a depressive and/or anxiety disorder was used in one of the included studies. As described above, there was a great variation between the studies in their conceptualization of depression and anxiety. There was also a great variation in the terminology used to express these conditions (e.g., depressed mood, depressive symptoms, and depression). Only one study (Joling et al., 2015) used a diagnostic measure to establish depression and anxiety disorders among carers. Therefore, the use of the terms “depression” and “anxiety,” which implies diagnosis, is not warranted for the majority of studies. As such, we have used the term “depressive symptoms” and “anxiety symptoms” throughout the Results section, except for results pertaining to Joling and colleagues (2015). Findings The results from the 26 quantitative studies included in this review are discussed below. The association between factors and depression and anxiety symptoms are discussed under the following headings: (1) Carer demographics; (2) Dementia characteristics; (3) Carer psychological and social factors; and (4) Dyadic relationship factors. Carer Demographics The association between carer demographic factors (i.e., age, gender, education, ethnicity, marital status, parity, and socioeconomic status) and carer experiences of depressive symptomatology was investigated in eight studies (Adams, Aranda, Kemp, & Takagi, 2002; Clay, Roth, Wadley, & Haley, 2008; Huang, 2004; McCallum, Longmire, & Knight, 2007; O’Rourke et al., 2010; Pöysti et al., 2012; Rankin, Haut, & Keefover, 2001; Rosness, Mjorud, & Engedal, 2011). The association between gender and spousal carer depressive symptoms was consistent across all three studies reporting on this relationship, with Adams and colleagues (2002), Pöysti and colleagues (2012), and Rankin and colleagues (2001) finding that female carers reported significantly higher levels of depressive symptoms than male carers. In addition, Adams and colleagues (2002) found a significantly higher percentage of females compared with males reported “clinically significant depressive symptoms.” The relationship between carer ethnicity and depressive symptoms was examined in three studies (Adams et al., 2002; Clay et al., 2008; McCallum et al., 2007); however, results were mixed. Adams and colleagues (2002) compared depressive symptoms of spousal carers across four different ethnic groups and demonstrated that the Mexican American carers reported significantly higher levels of depressive symptoms than African American and Anglo American carers. In contrast, Clay and colleagues (2008) demonstrated that their subsample of White carers (both spousal and adult–child carers) reported significantly higher levels of depressive symptoms compared with African American carers across the 5-year longitudinal study. Lastly, in their comparison of female spousal and adult–child carers across two ethnic groups, McCallum and colleagues (2007) found no significant difference in the depressive symptoms reported by African American carers and European American carers. Socioeconomic status was investigated in two studies, with both Clay and colleagues (2008) and Huang (2004) finding that lower socioeconomic status was related to greater depressive symptoms for carers (both studies sampled spousal and adult–child carers). Carer age and level of educational attainment were significantly associated with depressive symptoms, with those who were younger in age and had fewer years of formal education reporting more depressive symptoms (O’Rourke et al., 2010). Lastly (removed reference to “being married”) and having children was significantly associated with higher depressive symptoms for the spousal carers of partners with early-onset dementia (Rosness et al., 2011). Dementia Characteristics Seven studies investigated the relationship between specific dementia characteristics (i.e., symptoms, stage of dementia) and the carer experiences of depressive and anxiety symptoms (Chun, Knight, & Youn, 2007; Huang, 2004; Mausbach et al., 2006, 2012; O’Rourke et al., 2010; Romero-Moreno et al., 2014; Wojtyna & Popiołek, 2012). The association between the progression of the dementia and carer depressive symptoms was investigated in two studies (O’Rourke et al., 2010; Wojtyna & Popiołek, 2012). O’Rourke and colleagues (2010) found that symptom severity and time since dementia diagnosis were significantly associated with an increase in spousal carers’ depressive symptoms between time points; Wojtyna and Popiołek (2012) demonstrated that spousal carers reported greater depressive symptoms when they were providing care for a care recipient who was more dependent on them and required a greater amount of time for daily care (Wojtyna & Popiołek, 2012). Five of the included studies demonstrated the negative role of problematic behaviors exhibited by the care recipient (Chun et al., 2007; Huang, 2004; Mausbach et al., 2006, 2012; Romero-Moreno et al., 2014). Problematic behaviors included repeatedly asking questions, becoming distressed or aggressive, and keeping the carer awake (Mausbach et al., 2012; Morano, 2003). Three studies demonstrated that carers’ depressive symptoms were positively associated with the frequency of the care recipients’ problematic behaviors (Huang, 2004; Mausbach et al., 2006, 2012). This relationship was significant between husband, wife, and daughter carers (Huang, 2004; Mausbach et al., 2006, 2012). Specific to daughter carers, Romero-Moreno and colleagues (2014) found that the frequency of problematic behaviors had a significant main effect on depressive symptoms. Furthermore, Chun and colleagues (2007) found that for White-American spousal and adult–child carers care recipients’ disruptive behaviors were predictive of greater burden, and consequently greater depressive and anxiety symptoms. Carer Psychological and Social Factors A total of 16 studies examined the relationship between psychological (e.g., carer burden and self-efficacy) and social (e.g., social support) factors on carers’ depressive and anxiety symptomatology (Clay et al., 2008; Epstein-Lubow et al., 2008; Gallant & Connell, 2003; Hayslip, Han, & Anderson, 2008; Huang, 2004; Joling et al., 2015; Mausbach et al., 2006, 2007, 2008, 2012; Morano, 2003; O’Rourke et al., 2010; Pioli, 2010; Rankin et al., 2001; Romero-Moreno et al., 2014; Williams, 2011). Carer burden was consistently found to have a significant positive relationship with carer depressive symptoms (Epstein-Lubow et al., 2008; Rankin et al., 2001; Williams, 2011). Epstein-Lubow and colleagues (2008) examined the relationship between carer burden and depressive symptoms over time among American carers and found that baseline depressive symptoms and carer burden were significant predictors of later depressive symptoms for spousal and adult–child carers. Rankin and colleagues (2001) and Williams (2011) also found positive associations between depressive symptoms and burden among American spousal carers. In addition, Morano (2003) investigated the relationship between carers’ appraisal of burden, caregiver stress (as a result of care recipient problematic behavior), and carer depressive symptoms. They found that appraisal of burden mediated the effects of problematic behavior on carers’ depressive symptoms (Morano, 2003). Three studies investigated the relationship between carer activity restriction (i.e., the restriction of social and recreational activities) and carers’ depressive symptoms (Mausbach et al., 2008, 2012; Romero-Moreno et al., 2014). Mausbach and colleagues (2008,,2012) found that carers who experienced increased activity restriction reported significantly greater depressive symptoms. Romero-Moreno and colleagues (2014) explored the role of carers’ feelings of guilt as a moderator in the relationship between leisure activities and depressive symptoms. Carers’ guilt included guilt about doing wrong by the care recipient, guilt about failing to meet the challenges of caregiving, and guilt about self-care. For the subsample of daughter carers, total feelings of guilt moderated the relationship between frequency of engagement with leisure activities and depressive symptoms, where those with increased feelings of guilt engaged in less leisure activities and experienced greater depressive symptoms (Romero-Moreno et al., 2014). However, Romero-Moreno and colleagues (2014) did not find significant results for the direct effect of leisure activities or moderator role of guilt for the subsamples of husbands, wives, or sons. The association between carers’ coping efforts and their depressive symptoms was examined in four studies (Huang, 2004; Mausbach et al., 2006,,2012; Morano, 2003). Three studies demonstrated that avoidance coping (avoidance of dealing with stressors) mediated the relationship between care recipient behavioral problems and carer depressive symptoms (Huang, 2004; Mausbach et al., 2006, 2012). The effect of behavioral problems on carer depressive symptoms was no longer significant when avoidance coping was accounted for. Significant findings were also reported by Morano (2003), where emotion-focused coping (managing the emotional responses to the stresses) moderated the effect of problematic behavior on carer depressive symptoms. Mastery, self-efficacy, and resilience were examined as specific coping responses in relation to depressive and anxiety symptoms in four studies (Mausbach et al., 2007, 2012; O’Rourke et al., 2010; Pioli, 2010). Mausbach and colleagues (2012) found that mastery and self-efficacy were inversely associated with depressive symptoms for spousal carers, after controlling for role overload. Both Mausbach and colleagues (2007) and Pioli (2010) reported a significant main effect for mastery, where increases in mastery resulted in decreases in spousal carer depressive symptoms. In addition, both Mausbach and colleagues (2007) and Pioli (2010) found a significant interaction for mastery and role overload with carer depressive symptoms, where there was a significant relationship between role overload and spousal carer depressive symptoms when mastery was low. Pioli (2010) also found that mastery was a significant moderator of the relationship between role overload and carer anxiety symptoms. Lastly, O’Rourke and colleagues (2010) examined whether psychological resilience played a protective role against depressive symptoms for spousal carers. O’Rourke and colleagues (2010) found that carers who reported higher levels of perceived control (i.e., the belief one can affect the conditions of life) and challenge (i.e., the belief that challenges provide opportunities to increase skills and self-knowledge) at baseline reported significantly lower levels of depressive symptoms 1 year later. Both formal and informal social support had a positive impact on carers’ depressive symptoms (Clay et al., 2008; Huang, 2004). Clay and colleagues (2008) examined the impact of informal social support on adult–child carers’ depressive symptoms. Clay and colleagues (2008) demonstrated that satisfaction with support was a significant predictor of fewer depressive symptoms, after controlling for the number of social supports available to the carer. Huang (2004) examined the influence of formal social support in the form of a paid helper. A significant negative correlation was found between carer depressive symptoms and having a paid helper, where carers with a paid helper experienced fewer depressive symptoms (Huang, 2004). The influence of personality characteristics on carer depressive symptoms was reported in two studies (Gallant & Connell, 2003; Hayslip et al., 2008). Gallant and Connell (2003) examined neuroticism in isolation, and found that higher levels of neuroticism were significantly related to higher levels of depressive symptoms for their sample of spousal carers. In contrast, Hayslip and colleagues (2008) included a more comprehensive representation of personality with the examination of the role of the five factor personality traits (i.e., neuroticism, openness, agreeability, extraversion, conscientiousness). Hayslip and colleagues (2008) demonstrated that collectively the personality traits significantly predicted increased depressed mood for both spousal and adult–child carers. When considered in isolation, extraversion was the only personality trait that uniquely predicted depressed mood, where more introverted carers experienced more depressed mood (Hayslip et al., 2008). The effect of existing symptoms on carers’ current experience of anxiety and depressive symptoms was examined in two studies (Hayslip et al., 2008; Joling et al., 2015). Joling and colleagues (2015) was the only study to investigate the predictors of depressive and anxiety disorders for spousal carers over time. They found that sub-threshold depressive symptoms at baseline predicted later onset of a depressive or anxiety disorder (Joling et al., 2015). Hayslip and colleagues (2008) explored the relationship between anxiety about ageing and carer depressive symptoms, sampling both adult–child carers and spousal carers. Anxiety about aging uniquely predicted depressed mood, indicating that carers who were more anxious about their aging experienced more depressive symptoms (Hayslip et al., 2008). Dyadic Relationship Factors Six studies investigated how the relationship between the carer and care recipient impacted carers’ experiences of depressive symptomatology (Beeson, Horton-Deutsch, Farran, & Neundorfer, 2000; Braun, Mura, Peter-Wight, Hornung, & Scholz, 2010; Chun et al., 2007; Fauth et al., 2012; Luchsinger et al., 2015; Rankin et al., 2001). The type of relationship between the carer and care recipient (i.e., spousal or adult–child) was examined in two studies (Chun et al., 2007; Luchsinger et al., 2015). Chun and colleagues (2007) found that adult–child carers reported higher depressive symptoms compared with spousal carers. However, Luchsinger and colleagues (2015) failed to find a significant relationship between carer relationship and depressive symptoms. The remaining four studies examined the role of relationship quality, finding that poor relationship quality was consistently linked to greater depressive symptoms for carers (Beeson et al., 2000; Braun et al., 2010; Fauth et al., 2012; Rankin et al., 2001). Braun and colleagues (2010) investigated the relationship between caregiver depression and quality of marital communication, and found carer depressive symptoms were significantly negatively associated with the care recipients’ positive communication. Beeson and colleagues (2000) found significant positive correlations between spousal carer depressive symptoms and relationship factors including poor quality of relationships and relational deprivation. Relational deprivation was conceptualized as the loss of exchange of intimacy, goals, and social activities shared within the relationship. The researchers found that greater depressive symptoms were related to greater feelings of relational deprivation and poorer relationship quality for carers. In addition, Fauth and colleagues (2012) found that spousal carers who reported higher levels of closeness within their relationship reported significantly lower depressive symptoms. Lastly, Rankin and colleagues (2001) classified spousal carers by their depression status (experiencing depression or not) and compared their perceptions of relationship quality. They found that the subsample of depressed spousal carers reported significantly lower levels of family satisfaction and marital cohesion. Discussion The aim of this systematic review was to investigate the factors that are associated with depression and anxiety for family carers of PWD. This study reviewed 26 studies that examined a wide range of factors in relation to carer depression and/or anxiety, including demographic factors, dementia characteristics, carer psychological and social factors, and factors related to the dyadic relationship. Psychological factors received the most attention in the studies, most notably carer burden (Epstein-Lubow et al., 2008; Morano, 2003; Rankin et al., 2001; Williams, 2011), coping styles (Huang, 2004; Mausbach et al., 2006, 2012; Morano, 2003), and specific coping responses such as self-efficacy (Mausbach et al., 2007, 2012; O’Rourke et al., 2010; Pioli, 2010). Dementia characteristics were also well represented, with studies consistently reporting on the role of problematic behaviors exhibited by care recipients (Chun et al., 2007; Huang, 2004; Mausbach et al., 2006, 2012; Romero-Moreno et al., 2014). Although there were a wide range of risk factors that were identified, there were some prominent factors that were consistently associated with depression across studies. Female caregivers were more at risk for depression (Adams et al., 2002; Pöysti et al., 2012; Rankin et al., 2001). Care recipient factors such as severity of dementia problematic behaviors were also found to be important risk factors for depressive (Huang, 2004; Mausbach et al., 2006, 2012) and anxiety (Chun et al., 2007) symptoms among carers. It is important to understand the demographic and dementia – specific factors that place family carers at risk of depression and anxiety, so that at risk populations can be targeted for both prevention and intervention program in mental health. In terms of psychological factors, coping strategies were found to be strongly related to depressive symptoms. Using avoidant coping strategies was found to be associated with higher carer depressive symptoms (Huang, 2004; Mausbach et al., 2006, 2012), whereas managing emotional responses to stress was associated with lower levels of carer depressive symptoms (Morano, 2003). Further, higher levels of mastery, self-efficacy, and resilience were related to lower levels of depressive (Mausbach et al., 2007, 2012; Pioli, 2010) and anxiety symptoms (Pioli, 2010). These findings add to the existing understanding of depression and anxiety among dementia family caregivers by clearly identifying the areas to target to strengthen the mental health of family carers. Some of the key risk factors identified in this review are also prominent risk factors for carer stress and burden (Etters et al., 2008; van der Lee, Bakker, Duivenvoorden, & Dröes, 2015; O’Dwyer, Moyle, Zimmer-Gembeck, & De Leo, 2016). However, the current findings highlighted some risk factors for depressive symptoms which are not major risk factors for stress and burden. For example, increased activity restriction (Mausbach et al., 2008, 2012; Romero-Moreno et al., 2014), where carers were restricted in their social activities, were related to depressive and anxiety symptoms, but not burden. Relationship type and quality were important factors associated with depressive symptoms. An interesting finding was that adult–child carers, rather than spousal carers, were more at risk of depressive symptoms and so should be specifically targeted in mental health programs. Enhancing closeness and intimacy as well as enhancing the quality of the relationship should all be targets in preventing and treating depression among family carers. Although this review highlights some of the prominent risk factors for dementia carers’ depressive symptoms, there are several important limitations within the currently available evidence. The studies were characterized by a lack of depth and precision. There was little consideration within the studies of the interplay between multiple factors. For example, few studies examined whether the combination of carers’ psychological factors and care recipient dementia characteristics made carers particularly susceptible to depression and anxiety symptoms. Due to the lack of research, no interpretations can be made about whether there are specific pathways or critical factors that accumulate to result in depressive and anxiety symptoms. The use of cross-sectional designs in the majority of studies also limits the conclusions that can be drawn about the potential causes of carers depressive and anxiety symptoms and the changes over time. The use of cross-sectional designs also limits the ability to examine important mediating factors that may contribute to the understanding of the ways other factors interact with caregivers’ experiences of depression and anxiety. Prospective studies tracking carers across their caregiving experiences would provide greater insight into whether there are periods of risk where they are more vulnerable to developing depression or anxiety, and what critical factors increase family carers’ vulnerability to depression and anxiety at specific points of time. Studies need to consider the impact of the length of time providing care on family carers’ depressive and anxiety symptoms. Within the included studies, there was limited detail about the length of time the carers had been providing care. In addition, studies need to account for carers’ experiences of depressive and anxiety symptoms prior to becoming a carer, and how this may contribute to the progression and severity of depression and anxiety across the caregiving experience. Joling and colleagues (2015) was the only study included in the review to investigate the impact of existing sub-threshold symptoms on the future development of diagnosed depression and anxiety. The studies identified within the review showed variability in the measures used to assess depressive and/or anxiety symptoms. Scales represented in the studies differed on the nature of the depressive and anxiety symptoms that were evaluated, the time frame specified, the level of endorsement of symptoms, and the meaning of the final score. For example, the Centre for Epidemiological Studies Depression Scale (Radloff, 1977) used a total of 20 items to assess depressive symptomatology, including depressed affect, positive affect, somatic difficulties, retarded activity, and interpersonal relationship problems. Participants were asked to rely on the time frame of “the past week” and rate the items according to the frequency of the symptom (ranging from “rarely or none of the time, <1 day” to “most or all of the time, 5–7 days”) (Radloff, 1977). In contrast, the Geriatric Depression Scale (Sheikh & Yesavage, 1986; Yesavage et al., 1982) focused exclusively on the affective and cognitive symptoms of depression with the 30 items, including apathy, sadness, crying, and thoughts of helplessness, worthlessness, guilt, and hopelessness. Items are endorsed for their “current” presence (yes/no) (Sheikh & Yesavage, 1986; Yesavage et al., 1982). This inconsistency and variability in symptoms and the ways in which they were assessed (including severity and frequency) limits comparability of results. While there is less variability in the scales used to assess anxiety symptoms, this is not because of greater consistency of measures but rather a lack of studies that examined carers’ experiences of anxiety. Only three of the studies examined anxiety symptoms, and two scales were used to assess the anxiety symptoms (Chun et al., 2007; Joling et al., 2015; Pioli, 2010). The use of appropriate scales that are valid and reliable in their assessment of depressive and anxiety symptoms will ensure that findings generated from future research can be meaningfully compared. Only one study utilized a clinical interview with strict diagnostic criteria to assess whether the participant was experiencing a depressive or anxiety disorder (Joling et al., 2015). While other scales provided cutoffs for the final score to suggest risk of a clinical disorder or severity of the depression or anxiety (i.e., mild, moderate, or severe), these did not map onto diagnostic criteria. Future research investigating the experience of depression and anxiety for family carers would benefit from the inclusion of a clinical interview such as the Mini-International Neuropsychiatric Interview (Sheehan et al., 1998) or Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (First, Williams, Karg, & Spitzer, 2015), to ensure appropriate assessment of depression and anxiety as clinical disorders. Furthermore, examination of anxiety and depression within the same sample (see Joling et al., 2015) would provide greater insight into how anxiety and depression manifest for family carers of PWD. For example, it is important to examine whether there is an overlap of symptoms and comorbidity of disorders (Joling et al., 2010) and whether there are common risk factors that contribute to both disorders. Examination of depression and anxiety as clinical disorders within research has important clinical implications. Clinicians interacting with both the PWD and their family carers need to be able to accurately identify those family carers who are at risk of, or are currently experiencing, depression and anxiety. In order to achieve this, clinicians require an understanding of how depression and anxiety manifest for family carers, as well as how key risk factors contribute to the development or exacerbation of the depression and anxiety. Conclusion This review examined those factors associated with depression and anxiety for family carers of PWD. Findings indicated depressive and anxiety symptoms are related to a range of carer demographic factors, dementia characteristics, carer psychological and social factors, and dyadic relationship factors. However, a lack of measurement precision and a reliance on cross-sectional studies limits our understanding of exactly how depression and anxiety progress during the caregiving experience and the factors that increase family carers’ risk of developing depression and anxiety. The implications for prevention and intervention programs for depression and anxiety are discussed, as well as suggestions for future research to improve the quality of research in this area. Supplementary Data Supplementary data are available at The Gerontologist online. Funding None reported. Conflict of Interest None reported. References Adams , B. , Aranda , M. P. , Kemp , B. , & Takagi , K . ( 2002 ). Ethnic and gender differences in distress among Anglo American, African American, Japanese American, and Mexican American spousal caregivers of persons with dementia . 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Depression and Anxiety Among Partner and Offspring Carers of People With Dementia: A Systematic Review

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© The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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Abstract Background and Objectives Family carers of people with dementia (PWD) experience high rates of depression and anxiety. However, the factors that are associated with these mental health concerns among family carers are not well understood. The purpose of this review was to identify factors that are associated with depression and anxiety in family carers of PWD. Research Design and Methods A systematic review was conducted of studies that examined depressive or anxiety symptoms among family caregivers of community-dwelling older adults with dementia. Twenty-six studies met inclusion criteria and were included in the review. Results Depressive and anxiety symptoms were related to demographic factors, dementia characteristics, carer psychological and social factors, and dyadic relationship factors. Some prominent factors were consistently associated with depressive symptoms across studies. Female carers and adult–child carers, rather than spousal carers, were more likely to experience depressive symptoms. Carers’ coping strategies and activity restriction were also found to be strongly related to depressive symptoms. Severity of dementia-related problematic behaviors was related to carers’ depression and anxiety symptoms. In addition, relationship type and quality were important factors associated with depressive symptoms. Discussion and Implications Several important risk factors for carer depression were highlighted in this review. However, a lack of measurement precision and a reliance on cross-sectional studies limits our understanding of exactly how depression and anxiety progress during the caregiving experience. The implications for prevention and intervention programs for depression and anxiety are discussed, as well as suggestions for future research to improve the quality of research in this area. Systematic review, Caregiving-informal, Depression, Dementia Family carers of people with dementia (PWD) are at greater risk of developing depression and anxiety compared with other carers and people in the general community (D’Aoust, Brewster, & Rowe, 2015; Etters, Goodall, & Harrison, 2008; Fonareva & Oken, 2014; Joling et al., 2010). For example, up to 80% of dementia family carers experience depression, compared with 6%–9% in the general population of adults over the age of 55 (Schoenmakers, Buntinx, & Delepeleire, 2010). The experience of chronic stress and psychological morbidity not only results in negative consequences for the carer, but can compromise the quality of care the carer is able to provide for the PWD (Etters et al., 2008; Fonareva & Oken, 2014; Leach, Francis, & Ziaian, 2014) and contributes to the development of negative feelings toward the PWD (Michon, Weber, Rudhard-Thomazic, & Giannakopoulos, 2005). Reducing the distress and psychological morbidity experienced by family carers of PWD is necessary to enable the family carers to continue to provide care within the home (Joling et al., 2010). Most research that has examined dementia family caregivers’ mental health and well-being has focused on stress and has sought to identify factors that contribute to caregivers’ stress and burden (e.g., Etters et al., 2008; Thies & Bleiler, 2013). As such, the risk factors for chronic stress and burden associated with of the role of being a family carer for a PWD have been well documented (Etters et al., 2008; Thies & Bleiler, 2013). However, depression and anxiety are different from stress and are likely to have different risk factors. Although depression and anxiety are highly prevalent among dementia family caregivers, less research has examined the factors that may contribute to the development of these conditions. Shua-Haim, Haim, Shi, Kuo, and Smith (2001) examined risk factors for depression among Alzheimer caregivers and found that care recipient characteristics, such as depression, a lower score on the mini mental status examination (MMSE), greater dependency and hallucinations were risk factors for caregivers’ depression (Shua-Haim et al., 2001). Other studies have examined contextual, psychological, and relationship risk factors for caregivers’ depression or anxiety. Some of the psychological factors that have been examined in relation to caregivers’ depression or anxiety include caregiver burden, coping strategies, self-efficacy, and feelings of guilt (Epstein-Lubow, Davis, Miller, & Tremont, 2008; Mausbach et al., 2012; Romero-Moreno et al., 2014). Although these papers provide some understanding of the factors associated with depression and anxiety among family carers of PWD, there has been no synthesis of the evidence on this important topic. Previous systematic reviews have investigated the prevalence of depressive and anxiety disorders for carers of PWD (Cooper, Balamurali, & Livingston, 2007; Cuijpers, 2005). However, research is needed to better understand the factors associated with depression and anxiety for carers of PWD and to know that the outcome variables are adequately evaluating depression and anxiety. The novel aspect of this review is that it examined what factors have been specifically associated with depression and anxiety among dementia caregivers and determined the current level of evidence for each of these factors. More specifically, this is the first systematic review to investigate the factors that are associated with depression and anxiety among family carers of PWD, including the factors that may contribute to, and exacerbate the development these conditions. As there have been no previous reviews on this topic, this review focused on immediate family carers because closer relationships are associated with increased carer burden (Etters et al., 2008). Therefore, the experience of depression and anxiety is also likely to be different for immediate family carers compared with “other” carers (e.g., grandchildren, siblings, and friends). The findings from this review will provide directions for further research and ultimately the design of new programs to prevent and treat depression and anxiety among family caregivers. Methods This review was informed by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff, & Altman, 2010). Search Strategy A search of four electronic databases (PsycInfo, Web of Science, MEDLINE, and CINAHL) was conducted in May 2017. The following search terms were used: (a) carer, caregiver, care giver, caring; (b) dementia or Alzheimer; and (c) depression, anxiety, or anxious. The complete search strategy is detailed in Supplementary material. The search was limited to studies published since 2000, as these reflect current research that is appropriate to inform current practice. The search was also limited to English language publications. Reference lists of included papers were searched for additional articles. Eligibility Criteria Following removal of duplicates, studies were screened for suitability via their titles and abstracts in Covidence© (Authors 1 and 2). Included papers focused specifically on immediate family (offspring and spouse/partner/de facto) carers of PWD because they usually have closest contact with the person with dementia and are more likely to be primary caregivers. It was also expected that closer familial relationships might be associated with increased caregiver burden and different experiences of anxiety and depression. Included papers also focused specifically on PWD who were community-dwelling. Additional inclusion criteria were that the study used a psychometrically sound measure of depression and anxiety as the outcome variable, and involved quantitative or qualitative methodologies. The term “Family caregivers” was not included in the search terms as this led to many of the relevant papers being excluded. Papers that were excluded were those that were opinion-pieces, editorials, reviews, books, dissertations, abstracts only, study protocols, or intervention or treatment/experimental studies, did not focus on participants who were current family carers of PWD (e.g., those carers who were no longer providing primary care for the PWD because the PWD had transitioned into an aged care facility or passed away, professional/staff carers, or carers of people who did not have dementia), did not include a specific focus on depression or anxiety (e.g., having a focus on mental health or carer burden), and did not include a psychometrically sound measure of depression and anxiety as the outcome variable. Following initial screening, the full-text articles were examined to determine eligibility for inclusion in the systematic review. Studies were read in their entirety to determine whether they sufficiently investigated the search terms. Any conflicts that occurred were resolved by a third reviewer (Author 3). Data Extraction Data from the studies were manually collated into matrices in Microsoft Excel to enable a comparison of the studies’ aims, samples, measures of depression and anxiety, methodologies, and results. Data extraction was completed by two reviewers (Authors 1 and 2) independently. Data Analysis Data from the quantitative studies were not able to be synthesized using a meta-analysis due to the heterogeneity of the methodologies adopted by the studies. Instead, the key findings for the included studies were appraised and summarized in a narrative synthesis. Results Study Selection The initial search revealed 8,581 records. After the removal of duplicates, 5,227 studies were screened by title and abstract. A total of 127 studies were read as full-text after the removal of 5,099 studies considered ineligible. The final sample was formed by 26 studies that were considered to meet the inclusion criteria. Figure 1 illustrates the screening process. Details of the included studies, their design, methodology, depression and/or anxiety measures used, and main findings are presented in Table 1. Table 1. Summary of Included Studies in the Systematic Review Author (year) country Aims Sample characteristics Study methodology Results Adams and colleagues (2002) USA To investigate similarities and differences in coping across four ethnic groups. n = 202 spousal carers. Carer gender: 67.3% females Carer M age: 67.4–71.9 Design: Cross-sectional. Outcome measure: Older Adult Health and Mood Questionnaire (OAHMQ) Analysis: Multivariate analysis of variance and chi-square. A greater percentage of Mexican American carers reported clinically significantly depressive symptoms, followed by Anglo American carers and African American carers. Female carers were more likely to report depressive symptoms compared with male carers. Beeson and colleagues (2000) USA To examine relationships between depression, relationship quality, and distance felt due to caregiving. n = 242 spousal or daughter carers. Carer gender: 65.0% females. Carer M age: 72.0 for husbands; 70.0 for wives; 52.0 for daughters. PWD M age: 74. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Significant positive correlations were found between depressive symptoms and relational deprivation, quality of the past relationship, and quality of the current relationship. Braun and colleagues (2010) Switzerland To investigate the relationship between depression and marital communication. n = 37 female spousal carers. Carer M age: 67.35. PWD M age: 72.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carer depressive symptoms were significantly negatively associated with care receivers’ positive communication. Chun and colleagues (2007) USA To compare emotional distress among caregivers. n = 171 spousal and adult–child carers. Carer gender: 77.5% females. Carer M age: 53.3–67.7 Design: Cross-sectional. Outcome measure: CES-D State Trait Anxiety Inventory (STAI) Analysis: Path analysis. For White-American carers, care recipient disruptive behaviors were predictive of greater burden, depressive and anxiety symptoms. Carers of parents (compared with carers of spouses) had higher depressive symptoms. Clay and colleagues (2008) USA To investigate changes in social support and psychosocial outcomes in caregivers between ethnic groups. n = 166 spousal and adult–child carers. Carer gender: 69.1% females. Carer M age: 55.7 for African American; 63.4 for White. PWD M age: 74.9 for African American; 73.2 for White Design: Longitudinal. Outcome measure: CES-D Analysis: Linear random effects regression models. White carers reported significantly higher levels of depressive symptoms compared with African American carers across the 5 years. Satisfaction with support and socioeconomic status were significant predictors of depressive symptoms. Epstein-Lubow and colleagues (2008) USA To examine the relationship between burden and depression. n = 33 spousal and adult–child carers. Carer gender: 79.0% females. Carer M age: 60.7–65.5. PWD M age: 75.6. Design: Longitudinal. Outcome measure: Geriatric Depression Scale (GDS) Analysis: Pearson’s correlations and hierarchical regressions. Baseline depressive symptoms and persisting burden were predictive of depressive symptoms at Time 3. Fauth and colleagues (2012) USA To understand associations between relationship closeness and caregiver psychological well-being. n = 234 spousal and adult–child carers. Carer gender: 76.07% females. Carer M age: 69.47. PWD M age: 82.0. Design: Longitudinal. Outcome measure: Beck Depression Inventory (BDI) Analysis: Linear mixed models. Carers who reported higher levels of closeness at baseline reported significantly lower depressive symptoms at baseline. Closeness was not related to depressive symptoms over time and closeness change was not related to rate of change in depressive symptoms. Gallant and Connell (2003) USA To examine the relationship between health behaviors, neuroticism, and depressive symptoms. n = 233 spousal carers. Carer gender: 53.0% females. Carer M age: 68.0 Design: Cross-sectional. Outcome measure: CES-D Analysis: Path analysis. Higher levels of neuroticism were significantly related to higher levels of depressive symptoms. Hayslip and colleagues (2008) USA To determine what factors predict depressed mood for caregivers. n = 42 spousal and adult–child carers. Carer gender: 81.0% females. Carer M age: 55.0. Design: Cross-sectional. Outcome measure: GDS Analysis: Hierarchical regressions. Extraversion and anxiety about ageing uniquely predicted depressed mood. Huang (2004) Taiwan To examine the relationships among demographic factors, situational factors, and coping on health outcomes of female caregivers. n = 103 female spousal and daughter carers. Carer M age: 55.70. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations and multiple regression. Avoidance coping mediated the relationship between the care recipients’ behavioral problems and carer depressive symptoms. Joling and colleagues (2015) The Netherlands To identify significant predictors of depression and anxiety disorders in caregivers. n = 181 spousal carers. Carer gender: 69.6% females. Carer M age: 70.6. PWD M age: 74.4. Design: Longitudinal. Outcome measure: Mini-International Neuropsychiatric Interview (MINI) Analysis: Multivariate regression. Sub-threshold depressive symptoms predicted incidence of a depressive or anxiety disorder. Luchsinger and colleagues (2015) USA To examine the cross-sectional correlates of caregiver depressive symptoms. n = 139 spousal and adult–child carers. Carer gender: 85.7% females. Carer M age: 59.3. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations. There were no differences between spousal and adult–child carers in the depressive symptoms reported. Mausbach and colleagues (2006) USA To test associations between patient problem behaviors, escape-avoidance coping, and depressive symptoms. n = 95 spousal carers. Carer gender: 72.0% female. Carer M age: 72.7. Design: Cross-sectional. Outcome measure: Brief Symptom Inventory (BSI) Analysis: Regressions and Sobel test. Escape-avoidance coping significantly mediated the relationship between patient problem behaviors and depressive symptoms. Mausbach and colleagues (2008) USA To test whether activity restriction mediates the relationship between being a carer and depressive symptoms. n = 16 spousal Alzheimer carers. Carer gender: 76.0% female. Carer M age: 68.1. Design: Cross-sectional. Outcome measure: CES-D Analysis: Regressions and Sobel test. Activity restriction was a significant predictor of depressive symptoms, but caregiving status was not. The Sobel test of the indirect effect was significant. Mausbach and colleagues (2007) USA To evaluate the impact of personal mastery and caregiving stress on depressive symptoms. n = 130 spousal Alzheimer carers. Carer gender: 71.0% female. Carer M age: 72.8. Design: Longitudinal. Outcome measure: Hamilton Depression Rating Scale (HAM-D) Analysis: Linear mixed-effects regression models. Increases in mastery resulted in decreases in depressive symptoms. When mastery was low there was a significant relationship between overload and depressive symptoms. Mausbach and colleagues (2012) USA To evaluate a model to explain how stress is associated with depressive symptoms. n = 126 spousal Alzheimer carers. Carer gender: 70.6% females. Carer M age: 74.2. Design: Cross-sectional. Outcome measure: CES-D Analysis: Bivariate correlations and multiple regression. Decreased personal mastery and self-efficacy were associated with increased depressive symptoms. Increased avoidance coping and activity restriction were associated with increased depressive symptoms. Greater role overload was associated with greater depressive symptoms. McCallum and colleagues (2007) USA To compare caregiver mental health outcomes between African American and White caregivers. n = 70 spousal and daughter carers. Carer M age: ranged from 60.7 to 65.4. Design: Cross-sectional. Outcome measure: CES-D Analysis: T-tests. There were no significant differences in depressive symptoms on the basis of ethnicity. Morano (2003) USA To investigate the relationship between coping and psychological wellbeing. n = 204 spousal and adult–child carers. Carer gender: 71.0% females. Carer M age: 64.0. PWD M age: 79.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Least squares multiple regression. Appraisal of burden mediated the effects of the problematic behavior on depressive symptoms. Emotion-focused coping moderated the effect of problematic behavior on depressive symptoms. O’Rourke and colleagues (2010) Canada To examine whether resilience predicts depressive symptoms. n= 105 spousal carers. Carer gender: 55.2% females. Carer M age: 69.59. Design: Longitudinal. Outcome measure: CES-D Analysis: Multilevel modeling. Younger age of caregivers and low level of educational attainments were significant predictors of increased Time 2 depressive symptoms. Younger caregivers whose spouses had had their diagnoses for longer periods reported significantly more depressive symptoms. Symptom severity and time since patient diagnosis were significantly associated with change in depressive symptoms between time points. Higher levels of challenge (the belief that challenges provide opportunities to increase skills and self-knowledge) and perceived control predicted lower levels of depressive symptoms at Time 2. Pioli (2010) USA To test whether mastery moderates the impact of stressors on depressive and anxious symptoms. n = 200 spousal carers. Carer gender: 61.5% females. Carer M age: 72.9. Design: Cross-sectional. Outcome measure: Hopkins Symptom Checklist (HSCL) Analysis: Multivariate linear regressions. Caregiving mastery was a significant moderator for the relationship between both subjective demands and role captivity on depressive symptoms. Caregiving mastery was a significant moderator of the relationship between both role overload and role captivity on anxiety symptoms. Pöysti and colleagues (2012) Finland To compare the burden of male and female spousal caregivers. n= 335 spousal carers. Carer gender: 61.8% females. Carer M age: 77.8 PWD M age: 77.2 Design: Cross-sectional. Outcome measure: GDS Analysis: Mann–Whitney test. Female carers reported greater depressive symptoms compared with male carers. Rankin and colleagues (2001) USA To investigate the effect of marital functioning on caregivers mental health. n = 96 spousal carers. Carer gender: 53.0% females. Carer M age: 69.0. PWD M age: 70.9. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations, χ2 tests, t test, and path analyses. Carers with depression reported lower levels of marital cohesion and family satisfaction compared with those carers without depression. Romero-Moreno and colleagues (2014) Spain To examine the moderator role of guilt on the effect of leisure activities on caregivers’ depressive symptoms. n= 351 spousal and adult–child carers. Carer gender: 78.63% females. Carer M age: 60.19. PWD M age: 78.76. Design: Cross-sectional. Outcome Measure: CES-D Analysis: Hierarchical regressions. Frequency of behavioral problems and leisure activities, hours of caring, and guilt had a significant effect on depressive symptoms for daughters. Guilt was a significant moderator of the relationship between frequency of leisure activities and depressive symptoms for daughters. Rosness and colleagues (2011) Norway To investigate correlates of depressive symptoms for carers. n= 49 spousal or de facto carers. Carer Gender: 65.7% females for carers; 81.8% females for non- carers. Carer M age: 60.3. PWD M age: 60.1. Design: Cross-sectional. Outcome measure: GDS Analysis: Multiple regression. Being married and having children, having a care recipient with a cardiovascular disease or no domiciliary nursing care were significantly associated with higher depressive symptoms for the carers. Williams (2011) USA To identify risk factors within marital relationships for caregiver depression. n= 16 spousal carers. Carer gender: 68.7% females. Carer M age: 77.38. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carers who reported more burden also reported greater depressive symptoms. Wojtyna and Popiołek (2012) Poland To examine the relationships between psychophysical functioning of the care recipient and the psychological costs for the caregiver. n= 104 spousal or de facto carers. Carer gender: 58.65% females. Carer M age: 70.31. Design: Cross-sectional. Outcome measure: BDI Analysis: Pearson’s correlations, and multiple regression. Time of daily care (hours/day) and level of independence of the care recipient were significantly associated with depressive symptoms. Depression increased with a growing sense of loss, an extended time of daily care and a lower level of independence of the patient. Author (year) country Aims Sample characteristics Study methodology Results Adams and colleagues (2002) USA To investigate similarities and differences in coping across four ethnic groups. n = 202 spousal carers. Carer gender: 67.3% females Carer M age: 67.4–71.9 Design: Cross-sectional. Outcome measure: Older Adult Health and Mood Questionnaire (OAHMQ) Analysis: Multivariate analysis of variance and chi-square. A greater percentage of Mexican American carers reported clinically significantly depressive symptoms, followed by Anglo American carers and African American carers. Female carers were more likely to report depressive symptoms compared with male carers. Beeson and colleagues (2000) USA To examine relationships between depression, relationship quality, and distance felt due to caregiving. n = 242 spousal or daughter carers. Carer gender: 65.0% females. Carer M age: 72.0 for husbands; 70.0 for wives; 52.0 for daughters. PWD M age: 74. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Significant positive correlations were found between depressive symptoms and relational deprivation, quality of the past relationship, and quality of the current relationship. Braun and colleagues (2010) Switzerland To investigate the relationship between depression and marital communication. n = 37 female spousal carers. Carer M age: 67.35. PWD M age: 72.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carer depressive symptoms were significantly negatively associated with care receivers’ positive communication. Chun and colleagues (2007) USA To compare emotional distress among caregivers. n = 171 spousal and adult–child carers. Carer gender: 77.5% females. Carer M age: 53.3–67.7 Design: Cross-sectional. Outcome measure: CES-D State Trait Anxiety Inventory (STAI) Analysis: Path analysis. For White-American carers, care recipient disruptive behaviors were predictive of greater burden, depressive and anxiety symptoms. Carers of parents (compared with carers of spouses) had higher depressive symptoms. Clay and colleagues (2008) USA To investigate changes in social support and psychosocial outcomes in caregivers between ethnic groups. n = 166 spousal and adult–child carers. Carer gender: 69.1% females. Carer M age: 55.7 for African American; 63.4 for White. PWD M age: 74.9 for African American; 73.2 for White Design: Longitudinal. Outcome measure: CES-D Analysis: Linear random effects regression models. White carers reported significantly higher levels of depressive symptoms compared with African American carers across the 5 years. Satisfaction with support and socioeconomic status were significant predictors of depressive symptoms. Epstein-Lubow and colleagues (2008) USA To examine the relationship between burden and depression. n = 33 spousal and adult–child carers. Carer gender: 79.0% females. Carer M age: 60.7–65.5. PWD M age: 75.6. Design: Longitudinal. Outcome measure: Geriatric Depression Scale (GDS) Analysis: Pearson’s correlations and hierarchical regressions. Baseline depressive symptoms and persisting burden were predictive of depressive symptoms at Time 3. Fauth and colleagues (2012) USA To understand associations between relationship closeness and caregiver psychological well-being. n = 234 spousal and adult–child carers. Carer gender: 76.07% females. Carer M age: 69.47. PWD M age: 82.0. Design: Longitudinal. Outcome measure: Beck Depression Inventory (BDI) Analysis: Linear mixed models. Carers who reported higher levels of closeness at baseline reported significantly lower depressive symptoms at baseline. Closeness was not related to depressive symptoms over time and closeness change was not related to rate of change in depressive symptoms. Gallant and Connell (2003) USA To examine the relationship between health behaviors, neuroticism, and depressive symptoms. n = 233 spousal carers. Carer gender: 53.0% females. Carer M age: 68.0 Design: Cross-sectional. Outcome measure: CES-D Analysis: Path analysis. Higher levels of neuroticism were significantly related to higher levels of depressive symptoms. Hayslip and colleagues (2008) USA To determine what factors predict depressed mood for caregivers. n = 42 spousal and adult–child carers. Carer gender: 81.0% females. Carer M age: 55.0. Design: Cross-sectional. Outcome measure: GDS Analysis: Hierarchical regressions. Extraversion and anxiety about ageing uniquely predicted depressed mood. Huang (2004) Taiwan To examine the relationships among demographic factors, situational factors, and coping on health outcomes of female caregivers. n = 103 female spousal and daughter carers. Carer M age: 55.70. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations and multiple regression. Avoidance coping mediated the relationship between the care recipients’ behavioral problems and carer depressive symptoms. Joling and colleagues (2015) The Netherlands To identify significant predictors of depression and anxiety disorders in caregivers. n = 181 spousal carers. Carer gender: 69.6% females. Carer M age: 70.6. PWD M age: 74.4. Design: Longitudinal. Outcome measure: Mini-International Neuropsychiatric Interview (MINI) Analysis: Multivariate regression. Sub-threshold depressive symptoms predicted incidence of a depressive or anxiety disorder. Luchsinger and colleagues (2015) USA To examine the cross-sectional correlates of caregiver depressive symptoms. n = 139 spousal and adult–child carers. Carer gender: 85.7% females. Carer M age: 59.3. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations. There were no differences between spousal and adult–child carers in the depressive symptoms reported. Mausbach and colleagues (2006) USA To test associations between patient problem behaviors, escape-avoidance coping, and depressive symptoms. n = 95 spousal carers. Carer gender: 72.0% female. Carer M age: 72.7. Design: Cross-sectional. Outcome measure: Brief Symptom Inventory (BSI) Analysis: Regressions and Sobel test. Escape-avoidance coping significantly mediated the relationship between patient problem behaviors and depressive symptoms. Mausbach and colleagues (2008) USA To test whether activity restriction mediates the relationship between being a carer and depressive symptoms. n = 16 spousal Alzheimer carers. Carer gender: 76.0% female. Carer M age: 68.1. Design: Cross-sectional. Outcome measure: CES-D Analysis: Regressions and Sobel test. Activity restriction was a significant predictor of depressive symptoms, but caregiving status was not. The Sobel test of the indirect effect was significant. Mausbach and colleagues (2007) USA To evaluate the impact of personal mastery and caregiving stress on depressive symptoms. n = 130 spousal Alzheimer carers. Carer gender: 71.0% female. Carer M age: 72.8. Design: Longitudinal. Outcome measure: Hamilton Depression Rating Scale (HAM-D) Analysis: Linear mixed-effects regression models. Increases in mastery resulted in decreases in depressive symptoms. When mastery was low there was a significant relationship between overload and depressive symptoms. Mausbach and colleagues (2012) USA To evaluate a model to explain how stress is associated with depressive symptoms. n = 126 spousal Alzheimer carers. Carer gender: 70.6% females. Carer M age: 74.2. Design: Cross-sectional. Outcome measure: CES-D Analysis: Bivariate correlations and multiple regression. Decreased personal mastery and self-efficacy were associated with increased depressive symptoms. Increased avoidance coping and activity restriction were associated with increased depressive symptoms. Greater role overload was associated with greater depressive symptoms. McCallum and colleagues (2007) USA To compare caregiver mental health outcomes between African American and White caregivers. n = 70 spousal and daughter carers. Carer M age: ranged from 60.7 to 65.4. Design: Cross-sectional. Outcome measure: CES-D Analysis: T-tests. There were no significant differences in depressive symptoms on the basis of ethnicity. Morano (2003) USA To investigate the relationship between coping and psychological wellbeing. n = 204 spousal and adult–child carers. Carer gender: 71.0% females. Carer M age: 64.0. PWD M age: 79.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Least squares multiple regression. Appraisal of burden mediated the effects of the problematic behavior on depressive symptoms. Emotion-focused coping moderated the effect of problematic behavior on depressive symptoms. O’Rourke and colleagues (2010) Canada To examine whether resilience predicts depressive symptoms. n= 105 spousal carers. Carer gender: 55.2% females. Carer M age: 69.59. Design: Longitudinal. Outcome measure: CES-D Analysis: Multilevel modeling. Younger age of caregivers and low level of educational attainments were significant predictors of increased Time 2 depressive symptoms. Younger caregivers whose spouses had had their diagnoses for longer periods reported significantly more depressive symptoms. Symptom severity and time since patient diagnosis were significantly associated with change in depressive symptoms between time points. Higher levels of challenge (the belief that challenges provide opportunities to increase skills and self-knowledge) and perceived control predicted lower levels of depressive symptoms at Time 2. Pioli (2010) USA To test whether mastery moderates the impact of stressors on depressive and anxious symptoms. n = 200 spousal carers. Carer gender: 61.5% females. Carer M age: 72.9. Design: Cross-sectional. Outcome measure: Hopkins Symptom Checklist (HSCL) Analysis: Multivariate linear regressions. Caregiving mastery was a significant moderator for the relationship between both subjective demands and role captivity on depressive symptoms. Caregiving mastery was a significant moderator of the relationship between both role overload and role captivity on anxiety symptoms. Pöysti and colleagues (2012) Finland To compare the burden of male and female spousal caregivers. n= 335 spousal carers. Carer gender: 61.8% females. Carer M age: 77.8 PWD M age: 77.2 Design: Cross-sectional. Outcome measure: GDS Analysis: Mann–Whitney test. Female carers reported greater depressive symptoms compared with male carers. Rankin and colleagues (2001) USA To investigate the effect of marital functioning on caregivers mental health. n = 96 spousal carers. Carer gender: 53.0% females. Carer M age: 69.0. PWD M age: 70.9. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations, χ2 tests, t test, and path analyses. Carers with depression reported lower levels of marital cohesion and family satisfaction compared with those carers without depression. Romero-Moreno and colleagues (2014) Spain To examine the moderator role of guilt on the effect of leisure activities on caregivers’ depressive symptoms. n= 351 spousal and adult–child carers. Carer gender: 78.63% females. Carer M age: 60.19. PWD M age: 78.76. Design: Cross-sectional. Outcome Measure: CES-D Analysis: Hierarchical regressions. Frequency of behavioral problems and leisure activities, hours of caring, and guilt had a significant effect on depressive symptoms for daughters. Guilt was a significant moderator of the relationship between frequency of leisure activities and depressive symptoms for daughters. Rosness and colleagues (2011) Norway To investigate correlates of depressive symptoms for carers. n= 49 spousal or de facto carers. Carer Gender: 65.7% females for carers; 81.8% females for non- carers. Carer M age: 60.3. PWD M age: 60.1. Design: Cross-sectional. Outcome measure: GDS Analysis: Multiple regression. Being married and having children, having a care recipient with a cardiovascular disease or no domiciliary nursing care were significantly associated with higher depressive symptoms for the carers. Williams (2011) USA To identify risk factors within marital relationships for caregiver depression. n= 16 spousal carers. Carer gender: 68.7% females. Carer M age: 77.38. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carers who reported more burden also reported greater depressive symptoms. Wojtyna and Popiołek (2012) Poland To examine the relationships between psychophysical functioning of the care recipient and the psychological costs for the caregiver. n= 104 spousal or de facto carers. Carer gender: 58.65% females. Carer M age: 70.31. Design: Cross-sectional. Outcome measure: BDI Analysis: Pearson’s correlations, and multiple regression. Time of daily care (hours/day) and level of independence of the care recipient were significantly associated with depressive symptoms. Depression increased with a growing sense of loss, an extended time of daily care and a lower level of independence of the patient. View Large Table 1. Summary of Included Studies in the Systematic Review Author (year) country Aims Sample characteristics Study methodology Results Adams and colleagues (2002) USA To investigate similarities and differences in coping across four ethnic groups. n = 202 spousal carers. Carer gender: 67.3% females Carer M age: 67.4–71.9 Design: Cross-sectional. Outcome measure: Older Adult Health and Mood Questionnaire (OAHMQ) Analysis: Multivariate analysis of variance and chi-square. A greater percentage of Mexican American carers reported clinically significantly depressive symptoms, followed by Anglo American carers and African American carers. Female carers were more likely to report depressive symptoms compared with male carers. Beeson and colleagues (2000) USA To examine relationships between depression, relationship quality, and distance felt due to caregiving. n = 242 spousal or daughter carers. Carer gender: 65.0% females. Carer M age: 72.0 for husbands; 70.0 for wives; 52.0 for daughters. PWD M age: 74. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Significant positive correlations were found between depressive symptoms and relational deprivation, quality of the past relationship, and quality of the current relationship. Braun and colleagues (2010) Switzerland To investigate the relationship between depression and marital communication. n = 37 female spousal carers. Carer M age: 67.35. PWD M age: 72.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carer depressive symptoms were significantly negatively associated with care receivers’ positive communication. Chun and colleagues (2007) USA To compare emotional distress among caregivers. n = 171 spousal and adult–child carers. Carer gender: 77.5% females. Carer M age: 53.3–67.7 Design: Cross-sectional. Outcome measure: CES-D State Trait Anxiety Inventory (STAI) Analysis: Path analysis. For White-American carers, care recipient disruptive behaviors were predictive of greater burden, depressive and anxiety symptoms. Carers of parents (compared with carers of spouses) had higher depressive symptoms. Clay and colleagues (2008) USA To investigate changes in social support and psychosocial outcomes in caregivers between ethnic groups. n = 166 spousal and adult–child carers. Carer gender: 69.1% females. Carer M age: 55.7 for African American; 63.4 for White. PWD M age: 74.9 for African American; 73.2 for White Design: Longitudinal. Outcome measure: CES-D Analysis: Linear random effects regression models. White carers reported significantly higher levels of depressive symptoms compared with African American carers across the 5 years. Satisfaction with support and socioeconomic status were significant predictors of depressive symptoms. Epstein-Lubow and colleagues (2008) USA To examine the relationship between burden and depression. n = 33 spousal and adult–child carers. Carer gender: 79.0% females. Carer M age: 60.7–65.5. PWD M age: 75.6. Design: Longitudinal. Outcome measure: Geriatric Depression Scale (GDS) Analysis: Pearson’s correlations and hierarchical regressions. Baseline depressive symptoms and persisting burden were predictive of depressive symptoms at Time 3. Fauth and colleagues (2012) USA To understand associations between relationship closeness and caregiver psychological well-being. n = 234 spousal and adult–child carers. Carer gender: 76.07% females. Carer M age: 69.47. PWD M age: 82.0. Design: Longitudinal. Outcome measure: Beck Depression Inventory (BDI) Analysis: Linear mixed models. Carers who reported higher levels of closeness at baseline reported significantly lower depressive symptoms at baseline. Closeness was not related to depressive symptoms over time and closeness change was not related to rate of change in depressive symptoms. Gallant and Connell (2003) USA To examine the relationship between health behaviors, neuroticism, and depressive symptoms. n = 233 spousal carers. Carer gender: 53.0% females. Carer M age: 68.0 Design: Cross-sectional. Outcome measure: CES-D Analysis: Path analysis. Higher levels of neuroticism were significantly related to higher levels of depressive symptoms. Hayslip and colleagues (2008) USA To determine what factors predict depressed mood for caregivers. n = 42 spousal and adult–child carers. Carer gender: 81.0% females. Carer M age: 55.0. Design: Cross-sectional. Outcome measure: GDS Analysis: Hierarchical regressions. Extraversion and anxiety about ageing uniquely predicted depressed mood. Huang (2004) Taiwan To examine the relationships among demographic factors, situational factors, and coping on health outcomes of female caregivers. n = 103 female spousal and daughter carers. Carer M age: 55.70. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations and multiple regression. Avoidance coping mediated the relationship between the care recipients’ behavioral problems and carer depressive symptoms. Joling and colleagues (2015) The Netherlands To identify significant predictors of depression and anxiety disorders in caregivers. n = 181 spousal carers. Carer gender: 69.6% females. Carer M age: 70.6. PWD M age: 74.4. Design: Longitudinal. Outcome measure: Mini-International Neuropsychiatric Interview (MINI) Analysis: Multivariate regression. Sub-threshold depressive symptoms predicted incidence of a depressive or anxiety disorder. Luchsinger and colleagues (2015) USA To examine the cross-sectional correlates of caregiver depressive symptoms. n = 139 spousal and adult–child carers. Carer gender: 85.7% females. Carer M age: 59.3. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations. There were no differences between spousal and adult–child carers in the depressive symptoms reported. Mausbach and colleagues (2006) USA To test associations between patient problem behaviors, escape-avoidance coping, and depressive symptoms. n = 95 spousal carers. Carer gender: 72.0% female. Carer M age: 72.7. Design: Cross-sectional. Outcome measure: Brief Symptom Inventory (BSI) Analysis: Regressions and Sobel test. Escape-avoidance coping significantly mediated the relationship between patient problem behaviors and depressive symptoms. Mausbach and colleagues (2008) USA To test whether activity restriction mediates the relationship between being a carer and depressive symptoms. n = 16 spousal Alzheimer carers. Carer gender: 76.0% female. Carer M age: 68.1. Design: Cross-sectional. Outcome measure: CES-D Analysis: Regressions and Sobel test. Activity restriction was a significant predictor of depressive symptoms, but caregiving status was not. The Sobel test of the indirect effect was significant. Mausbach and colleagues (2007) USA To evaluate the impact of personal mastery and caregiving stress on depressive symptoms. n = 130 spousal Alzheimer carers. Carer gender: 71.0% female. Carer M age: 72.8. Design: Longitudinal. Outcome measure: Hamilton Depression Rating Scale (HAM-D) Analysis: Linear mixed-effects regression models. Increases in mastery resulted in decreases in depressive symptoms. When mastery was low there was a significant relationship between overload and depressive symptoms. Mausbach and colleagues (2012) USA To evaluate a model to explain how stress is associated with depressive symptoms. n = 126 spousal Alzheimer carers. Carer gender: 70.6% females. Carer M age: 74.2. Design: Cross-sectional. Outcome measure: CES-D Analysis: Bivariate correlations and multiple regression. Decreased personal mastery and self-efficacy were associated with increased depressive symptoms. Increased avoidance coping and activity restriction were associated with increased depressive symptoms. Greater role overload was associated with greater depressive symptoms. McCallum and colleagues (2007) USA To compare caregiver mental health outcomes between African American and White caregivers. n = 70 spousal and daughter carers. Carer M age: ranged from 60.7 to 65.4. Design: Cross-sectional. Outcome measure: CES-D Analysis: T-tests. There were no significant differences in depressive symptoms on the basis of ethnicity. Morano (2003) USA To investigate the relationship between coping and psychological wellbeing. n = 204 spousal and adult–child carers. Carer gender: 71.0% females. Carer M age: 64.0. PWD M age: 79.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Least squares multiple regression. Appraisal of burden mediated the effects of the problematic behavior on depressive symptoms. Emotion-focused coping moderated the effect of problematic behavior on depressive symptoms. O’Rourke and colleagues (2010) Canada To examine whether resilience predicts depressive symptoms. n= 105 spousal carers. Carer gender: 55.2% females. Carer M age: 69.59. Design: Longitudinal. Outcome measure: CES-D Analysis: Multilevel modeling. Younger age of caregivers and low level of educational attainments were significant predictors of increased Time 2 depressive symptoms. Younger caregivers whose spouses had had their diagnoses for longer periods reported significantly more depressive symptoms. Symptom severity and time since patient diagnosis were significantly associated with change in depressive symptoms between time points. Higher levels of challenge (the belief that challenges provide opportunities to increase skills and self-knowledge) and perceived control predicted lower levels of depressive symptoms at Time 2. Pioli (2010) USA To test whether mastery moderates the impact of stressors on depressive and anxious symptoms. n = 200 spousal carers. Carer gender: 61.5% females. Carer M age: 72.9. Design: Cross-sectional. Outcome measure: Hopkins Symptom Checklist (HSCL) Analysis: Multivariate linear regressions. Caregiving mastery was a significant moderator for the relationship between both subjective demands and role captivity on depressive symptoms. Caregiving mastery was a significant moderator of the relationship between both role overload and role captivity on anxiety symptoms. Pöysti and colleagues (2012) Finland To compare the burden of male and female spousal caregivers. n= 335 spousal carers. Carer gender: 61.8% females. Carer M age: 77.8 PWD M age: 77.2 Design: Cross-sectional. Outcome measure: GDS Analysis: Mann–Whitney test. Female carers reported greater depressive symptoms compared with male carers. Rankin and colleagues (2001) USA To investigate the effect of marital functioning on caregivers mental health. n = 96 spousal carers. Carer gender: 53.0% females. Carer M age: 69.0. PWD M age: 70.9. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations, χ2 tests, t test, and path analyses. Carers with depression reported lower levels of marital cohesion and family satisfaction compared with those carers without depression. Romero-Moreno and colleagues (2014) Spain To examine the moderator role of guilt on the effect of leisure activities on caregivers’ depressive symptoms. n= 351 spousal and adult–child carers. Carer gender: 78.63% females. Carer M age: 60.19. PWD M age: 78.76. Design: Cross-sectional. Outcome Measure: CES-D Analysis: Hierarchical regressions. Frequency of behavioral problems and leisure activities, hours of caring, and guilt had a significant effect on depressive symptoms for daughters. Guilt was a significant moderator of the relationship between frequency of leisure activities and depressive symptoms for daughters. Rosness and colleagues (2011) Norway To investigate correlates of depressive symptoms for carers. n= 49 spousal or de facto carers. Carer Gender: 65.7% females for carers; 81.8% females for non- carers. Carer M age: 60.3. PWD M age: 60.1. Design: Cross-sectional. Outcome measure: GDS Analysis: Multiple regression. Being married and having children, having a care recipient with a cardiovascular disease or no domiciliary nursing care were significantly associated with higher depressive symptoms for the carers. Williams (2011) USA To identify risk factors within marital relationships for caregiver depression. n= 16 spousal carers. Carer gender: 68.7% females. Carer M age: 77.38. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carers who reported more burden also reported greater depressive symptoms. Wojtyna and Popiołek (2012) Poland To examine the relationships between psychophysical functioning of the care recipient and the psychological costs for the caregiver. n= 104 spousal or de facto carers. Carer gender: 58.65% females. Carer M age: 70.31. Design: Cross-sectional. Outcome measure: BDI Analysis: Pearson’s correlations, and multiple regression. Time of daily care (hours/day) and level of independence of the care recipient were significantly associated with depressive symptoms. Depression increased with a growing sense of loss, an extended time of daily care and a lower level of independence of the patient. Author (year) country Aims Sample characteristics Study methodology Results Adams and colleagues (2002) USA To investigate similarities and differences in coping across four ethnic groups. n = 202 spousal carers. Carer gender: 67.3% females Carer M age: 67.4–71.9 Design: Cross-sectional. Outcome measure: Older Adult Health and Mood Questionnaire (OAHMQ) Analysis: Multivariate analysis of variance and chi-square. A greater percentage of Mexican American carers reported clinically significantly depressive symptoms, followed by Anglo American carers and African American carers. Female carers were more likely to report depressive symptoms compared with male carers. Beeson and colleagues (2000) USA To examine relationships between depression, relationship quality, and distance felt due to caregiving. n = 242 spousal or daughter carers. Carer gender: 65.0% females. Carer M age: 72.0 for husbands; 70.0 for wives; 52.0 for daughters. PWD M age: 74. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Significant positive correlations were found between depressive symptoms and relational deprivation, quality of the past relationship, and quality of the current relationship. Braun and colleagues (2010) Switzerland To investigate the relationship between depression and marital communication. n = 37 female spousal carers. Carer M age: 67.35. PWD M age: 72.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carer depressive symptoms were significantly negatively associated with care receivers’ positive communication. Chun and colleagues (2007) USA To compare emotional distress among caregivers. n = 171 spousal and adult–child carers. Carer gender: 77.5% females. Carer M age: 53.3–67.7 Design: Cross-sectional. Outcome measure: CES-D State Trait Anxiety Inventory (STAI) Analysis: Path analysis. For White-American carers, care recipient disruptive behaviors were predictive of greater burden, depressive and anxiety symptoms. Carers of parents (compared with carers of spouses) had higher depressive symptoms. Clay and colleagues (2008) USA To investigate changes in social support and psychosocial outcomes in caregivers between ethnic groups. n = 166 spousal and adult–child carers. Carer gender: 69.1% females. Carer M age: 55.7 for African American; 63.4 for White. PWD M age: 74.9 for African American; 73.2 for White Design: Longitudinal. Outcome measure: CES-D Analysis: Linear random effects regression models. White carers reported significantly higher levels of depressive symptoms compared with African American carers across the 5 years. Satisfaction with support and socioeconomic status were significant predictors of depressive symptoms. Epstein-Lubow and colleagues (2008) USA To examine the relationship between burden and depression. n = 33 spousal and adult–child carers. Carer gender: 79.0% females. Carer M age: 60.7–65.5. PWD M age: 75.6. Design: Longitudinal. Outcome measure: Geriatric Depression Scale (GDS) Analysis: Pearson’s correlations and hierarchical regressions. Baseline depressive symptoms and persisting burden were predictive of depressive symptoms at Time 3. Fauth and colleagues (2012) USA To understand associations between relationship closeness and caregiver psychological well-being. n = 234 spousal and adult–child carers. Carer gender: 76.07% females. Carer M age: 69.47. PWD M age: 82.0. Design: Longitudinal. Outcome measure: Beck Depression Inventory (BDI) Analysis: Linear mixed models. Carers who reported higher levels of closeness at baseline reported significantly lower depressive symptoms at baseline. Closeness was not related to depressive symptoms over time and closeness change was not related to rate of change in depressive symptoms. Gallant and Connell (2003) USA To examine the relationship between health behaviors, neuroticism, and depressive symptoms. n = 233 spousal carers. Carer gender: 53.0% females. Carer M age: 68.0 Design: Cross-sectional. Outcome measure: CES-D Analysis: Path analysis. Higher levels of neuroticism were significantly related to higher levels of depressive symptoms. Hayslip and colleagues (2008) USA To determine what factors predict depressed mood for caregivers. n = 42 spousal and adult–child carers. Carer gender: 81.0% females. Carer M age: 55.0. Design: Cross-sectional. Outcome measure: GDS Analysis: Hierarchical regressions. Extraversion and anxiety about ageing uniquely predicted depressed mood. Huang (2004) Taiwan To examine the relationships among demographic factors, situational factors, and coping on health outcomes of female caregivers. n = 103 female spousal and daughter carers. Carer M age: 55.70. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations and multiple regression. Avoidance coping mediated the relationship between the care recipients’ behavioral problems and carer depressive symptoms. Joling and colleagues (2015) The Netherlands To identify significant predictors of depression and anxiety disorders in caregivers. n = 181 spousal carers. Carer gender: 69.6% females. Carer M age: 70.6. PWD M age: 74.4. Design: Longitudinal. Outcome measure: Mini-International Neuropsychiatric Interview (MINI) Analysis: Multivariate regression. Sub-threshold depressive symptoms predicted incidence of a depressive or anxiety disorder. Luchsinger and colleagues (2015) USA To examine the cross-sectional correlates of caregiver depressive symptoms. n = 139 spousal and adult–child carers. Carer gender: 85.7% females. Carer M age: 59.3. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations. There were no differences between spousal and adult–child carers in the depressive symptoms reported. Mausbach and colleagues (2006) USA To test associations between patient problem behaviors, escape-avoidance coping, and depressive symptoms. n = 95 spousal carers. Carer gender: 72.0% female. Carer M age: 72.7. Design: Cross-sectional. Outcome measure: Brief Symptom Inventory (BSI) Analysis: Regressions and Sobel test. Escape-avoidance coping significantly mediated the relationship between patient problem behaviors and depressive symptoms. Mausbach and colleagues (2008) USA To test whether activity restriction mediates the relationship between being a carer and depressive symptoms. n = 16 spousal Alzheimer carers. Carer gender: 76.0% female. Carer M age: 68.1. Design: Cross-sectional. Outcome measure: CES-D Analysis: Regressions and Sobel test. Activity restriction was a significant predictor of depressive symptoms, but caregiving status was not. The Sobel test of the indirect effect was significant. Mausbach and colleagues (2007) USA To evaluate the impact of personal mastery and caregiving stress on depressive symptoms. n = 130 spousal Alzheimer carers. Carer gender: 71.0% female. Carer M age: 72.8. Design: Longitudinal. Outcome measure: Hamilton Depression Rating Scale (HAM-D) Analysis: Linear mixed-effects regression models. Increases in mastery resulted in decreases in depressive symptoms. When mastery was low there was a significant relationship between overload and depressive symptoms. Mausbach and colleagues (2012) USA To evaluate a model to explain how stress is associated with depressive symptoms. n = 126 spousal Alzheimer carers. Carer gender: 70.6% females. Carer M age: 74.2. Design: Cross-sectional. Outcome measure: CES-D Analysis: Bivariate correlations and multiple regression. Decreased personal mastery and self-efficacy were associated with increased depressive symptoms. Increased avoidance coping and activity restriction were associated with increased depressive symptoms. Greater role overload was associated with greater depressive symptoms. McCallum and colleagues (2007) USA To compare caregiver mental health outcomes between African American and White caregivers. n = 70 spousal and daughter carers. Carer M age: ranged from 60.7 to 65.4. Design: Cross-sectional. Outcome measure: CES-D Analysis: T-tests. There were no significant differences in depressive symptoms on the basis of ethnicity. Morano (2003) USA To investigate the relationship between coping and psychological wellbeing. n = 204 spousal and adult–child carers. Carer gender: 71.0% females. Carer M age: 64.0. PWD M age: 79.0. Design: Cross-sectional. Outcome measure: CES-D Analysis: Least squares multiple regression. Appraisal of burden mediated the effects of the problematic behavior on depressive symptoms. Emotion-focused coping moderated the effect of problematic behavior on depressive symptoms. O’Rourke and colleagues (2010) Canada To examine whether resilience predicts depressive symptoms. n= 105 spousal carers. Carer gender: 55.2% females. Carer M age: 69.59. Design: Longitudinal. Outcome measure: CES-D Analysis: Multilevel modeling. Younger age of caregivers and low level of educational attainments were significant predictors of increased Time 2 depressive symptoms. Younger caregivers whose spouses had had their diagnoses for longer periods reported significantly more depressive symptoms. Symptom severity and time since patient diagnosis were significantly associated with change in depressive symptoms between time points. Higher levels of challenge (the belief that challenges provide opportunities to increase skills and self-knowledge) and perceived control predicted lower levels of depressive symptoms at Time 2. Pioli (2010) USA To test whether mastery moderates the impact of stressors on depressive and anxious symptoms. n = 200 spousal carers. Carer gender: 61.5% females. Carer M age: 72.9. Design: Cross-sectional. Outcome measure: Hopkins Symptom Checklist (HSCL) Analysis: Multivariate linear regressions. Caregiving mastery was a significant moderator for the relationship between both subjective demands and role captivity on depressive symptoms. Caregiving mastery was a significant moderator of the relationship between both role overload and role captivity on anxiety symptoms. Pöysti and colleagues (2012) Finland To compare the burden of male and female spousal caregivers. n= 335 spousal carers. Carer gender: 61.8% females. Carer M age: 77.8 PWD M age: 77.2 Design: Cross-sectional. Outcome measure: GDS Analysis: Mann–Whitney test. Female carers reported greater depressive symptoms compared with male carers. Rankin and colleagues (2001) USA To investigate the effect of marital functioning on caregivers mental health. n = 96 spousal carers. Carer gender: 53.0% females. Carer M age: 69.0. PWD M age: 70.9. Design: Cross-sectional. Outcome measure: GDS Analysis: Pearson’s correlations, χ2 tests, t test, and path analyses. Carers with depression reported lower levels of marital cohesion and family satisfaction compared with those carers without depression. Romero-Moreno and colleagues (2014) Spain To examine the moderator role of guilt on the effect of leisure activities on caregivers’ depressive symptoms. n= 351 spousal and adult–child carers. Carer gender: 78.63% females. Carer M age: 60.19. PWD M age: 78.76. Design: Cross-sectional. Outcome Measure: CES-D Analysis: Hierarchical regressions. Frequency of behavioral problems and leisure activities, hours of caring, and guilt had a significant effect on depressive symptoms for daughters. Guilt was a significant moderator of the relationship between frequency of leisure activities and depressive symptoms for daughters. Rosness and colleagues (2011) Norway To investigate correlates of depressive symptoms for carers. n= 49 spousal or de facto carers. Carer Gender: 65.7% females for carers; 81.8% females for non- carers. Carer M age: 60.3. PWD M age: 60.1. Design: Cross-sectional. Outcome measure: GDS Analysis: Multiple regression. Being married and having children, having a care recipient with a cardiovascular disease or no domiciliary nursing care were significantly associated with higher depressive symptoms for the carers. Williams (2011) USA To identify risk factors within marital relationships for caregiver depression. n= 16 spousal carers. Carer gender: 68.7% females. Carer M age: 77.38. Design: Cross-sectional. Outcome measure: CES-D Analysis: Pearson’s correlations. Carers who reported more burden also reported greater depressive symptoms. Wojtyna and Popiołek (2012) Poland To examine the relationships between psychophysical functioning of the care recipient and the psychological costs for the caregiver. n= 104 spousal or de facto carers. Carer gender: 58.65% females. Carer M age: 70.31. Design: Cross-sectional. Outcome measure: BDI Analysis: Pearson’s correlations, and multiple regression. Time of daily care (hours/day) and level of independence of the care recipient were significantly associated with depressive symptoms. Depression increased with a growing sense of loss, an extended time of daily care and a lower level of independence of the patient. View Large Figure 1. View largeDownload slide Study screening process. Figure 1. View largeDownload slide Study screening process. Study Characteristics All of the 26 studies included in the review were quantitative in design; all but six of the studies were cross-sectional in design. A total of 18 studies were based in the United States; and one, respectively, in Canada, Switzerland, Taiwan, Finland, Spain, Norway, Poland, and the Netherlands. Sample sizes ranged from 16 to 351. Spousal and de facto carers were sampled exclusively in 15 of the studies, with the remaining 11 studies sampling both spousal and adult–child carers. The majority of studies included both female and male carers; three studies focused exclusively on female carers. Eight of the studies sampled specific dementia diagnoses (e.g., Alzheimer’s disease), and the remaining studies included people with any dementia diagnosis. All of the studies included depression as a focus; only three studies included anxiety as a focus. A total of nine scales were used across the included studies to measure depression and anxiety; seven self-report scales were used to measure depressive symptoms. The most consistently used measures of depressive symptoms were the Centre for Epidemiology Scale for Depression in Dementia (Radloff, 1977) and the Geriatric Depression Scale (Sheikh & Yesavage, 1986; Yesavage et al., 1982), which were used in 13 and 6 of the included studies, respectively. Two self-report measures were used to assess anxiety symptoms: the State Trait Anxiety Inventory (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1985) and the Hopkins Symptom Checklist (Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974). A structured diagnostic instrument, specifically the Mini-International Neuropsychiatric Interview (Sheehan et al., 1998), to assess the presence of a depressive and/or anxiety disorder was used in one of the included studies. As described above, there was a great variation between the studies in their conceptualization of depression and anxiety. There was also a great variation in the terminology used to express these conditions (e.g., depressed mood, depressive symptoms, and depression). Only one study (Joling et al., 2015) used a diagnostic measure to establish depression and anxiety disorders among carers. Therefore, the use of the terms “depression” and “anxiety,” which implies diagnosis, is not warranted for the majority of studies. As such, we have used the term “depressive symptoms” and “anxiety symptoms” throughout the Results section, except for results pertaining to Joling and colleagues (2015). Findings The results from the 26 quantitative studies included in this review are discussed below. The association between factors and depression and anxiety symptoms are discussed under the following headings: (1) Carer demographics; (2) Dementia characteristics; (3) Carer psychological and social factors; and (4) Dyadic relationship factors. Carer Demographics The association between carer demographic factors (i.e., age, gender, education, ethnicity, marital status, parity, and socioeconomic status) and carer experiences of depressive symptomatology was investigated in eight studies (Adams, Aranda, Kemp, & Takagi, 2002; Clay, Roth, Wadley, & Haley, 2008; Huang, 2004; McCallum, Longmire, & Knight, 2007; O’Rourke et al., 2010; Pöysti et al., 2012; Rankin, Haut, & Keefover, 2001; Rosness, Mjorud, & Engedal, 2011). The association between gender and spousal carer depressive symptoms was consistent across all three studies reporting on this relationship, with Adams and colleagues (2002), Pöysti and colleagues (2012), and Rankin and colleagues (2001) finding that female carers reported significantly higher levels of depressive symptoms than male carers. In addition, Adams and colleagues (2002) found a significantly higher percentage of females compared with males reported “clinically significant depressive symptoms.” The relationship between carer ethnicity and depressive symptoms was examined in three studies (Adams et al., 2002; Clay et al., 2008; McCallum et al., 2007); however, results were mixed. Adams and colleagues (2002) compared depressive symptoms of spousal carers across four different ethnic groups and demonstrated that the Mexican American carers reported significantly higher levels of depressive symptoms than African American and Anglo American carers. In contrast, Clay and colleagues (2008) demonstrated that their subsample of White carers (both spousal and adult–child carers) reported significantly higher levels of depressive symptoms compared with African American carers across the 5-year longitudinal study. Lastly, in their comparison of female spousal and adult–child carers across two ethnic groups, McCallum and colleagues (2007) found no significant difference in the depressive symptoms reported by African American carers and European American carers. Socioeconomic status was investigated in two studies, with both Clay and colleagues (2008) and Huang (2004) finding that lower socioeconomic status was related to greater depressive symptoms for carers (both studies sampled spousal and adult–child carers). Carer age and level of educational attainment were significantly associated with depressive symptoms, with those who were younger in age and had fewer years of formal education reporting more depressive symptoms (O’Rourke et al., 2010). Lastly (removed reference to “being married”) and having children was significantly associated with higher depressive symptoms for the spousal carers of partners with early-onset dementia (Rosness et al., 2011). Dementia Characteristics Seven studies investigated the relationship between specific dementia characteristics (i.e., symptoms, stage of dementia) and the carer experiences of depressive and anxiety symptoms (Chun, Knight, & Youn, 2007; Huang, 2004; Mausbach et al., 2006, 2012; O’Rourke et al., 2010; Romero-Moreno et al., 2014; Wojtyna & Popiołek, 2012). The association between the progression of the dementia and carer depressive symptoms was investigated in two studies (O’Rourke et al., 2010; Wojtyna & Popiołek, 2012). O’Rourke and colleagues (2010) found that symptom severity and time since dementia diagnosis were significantly associated with an increase in spousal carers’ depressive symptoms between time points; Wojtyna and Popiołek (2012) demonstrated that spousal carers reported greater depressive symptoms when they were providing care for a care recipient who was more dependent on them and required a greater amount of time for daily care (Wojtyna & Popiołek, 2012). Five of the included studies demonstrated the negative role of problematic behaviors exhibited by the care recipient (Chun et al., 2007; Huang, 2004; Mausbach et al., 2006, 2012; Romero-Moreno et al., 2014). Problematic behaviors included repeatedly asking questions, becoming distressed or aggressive, and keeping the carer awake (Mausbach et al., 2012; Morano, 2003). Three studies demonstrated that carers’ depressive symptoms were positively associated with the frequency of the care recipients’ problematic behaviors (Huang, 2004; Mausbach et al., 2006, 2012). This relationship was significant between husband, wife, and daughter carers (Huang, 2004; Mausbach et al., 2006, 2012). Specific to daughter carers, Romero-Moreno and colleagues (2014) found that the frequency of problematic behaviors had a significant main effect on depressive symptoms. Furthermore, Chun and colleagues (2007) found that for White-American spousal and adult–child carers care recipients’ disruptive behaviors were predictive of greater burden, and consequently greater depressive and anxiety symptoms. Carer Psychological and Social Factors A total of 16 studies examined the relationship between psychological (e.g., carer burden and self-efficacy) and social (e.g., social support) factors on carers’ depressive and anxiety symptomatology (Clay et al., 2008; Epstein-Lubow et al., 2008; Gallant & Connell, 2003; Hayslip, Han, & Anderson, 2008; Huang, 2004; Joling et al., 2015; Mausbach et al., 2006, 2007, 2008, 2012; Morano, 2003; O’Rourke et al., 2010; Pioli, 2010; Rankin et al., 2001; Romero-Moreno et al., 2014; Williams, 2011). Carer burden was consistently found to have a significant positive relationship with carer depressive symptoms (Epstein-Lubow et al., 2008; Rankin et al., 2001; Williams, 2011). Epstein-Lubow and colleagues (2008) examined the relationship between carer burden and depressive symptoms over time among American carers and found that baseline depressive symptoms and carer burden were significant predictors of later depressive symptoms for spousal and adult–child carers. Rankin and colleagues (2001) and Williams (2011) also found positive associations between depressive symptoms and burden among American spousal carers. In addition, Morano (2003) investigated the relationship between carers’ appraisal of burden, caregiver stress (as a result of care recipient problematic behavior), and carer depressive symptoms. They found that appraisal of burden mediated the effects of problematic behavior on carers’ depressive symptoms (Morano, 2003). Three studies investigated the relationship between carer activity restriction (i.e., the restriction of social and recreational activities) and carers’ depressive symptoms (Mausbach et al., 2008, 2012; Romero-Moreno et al., 2014). Mausbach and colleagues (2008,,2012) found that carers who experienced increased activity restriction reported significantly greater depressive symptoms. Romero-Moreno and colleagues (2014) explored the role of carers’ feelings of guilt as a moderator in the relationship between leisure activities and depressive symptoms. Carers’ guilt included guilt about doing wrong by the care recipient, guilt about failing to meet the challenges of caregiving, and guilt about self-care. For the subsample of daughter carers, total feelings of guilt moderated the relationship between frequency of engagement with leisure activities and depressive symptoms, where those with increased feelings of guilt engaged in less leisure activities and experienced greater depressive symptoms (Romero-Moreno et al., 2014). However, Romero-Moreno and colleagues (2014) did not find significant results for the direct effect of leisure activities or moderator role of guilt for the subsamples of husbands, wives, or sons. The association between carers’ coping efforts and their depressive symptoms was examined in four studies (Huang, 2004; Mausbach et al., 2006,,2012; Morano, 2003). Three studies demonstrated that avoidance coping (avoidance of dealing with stressors) mediated the relationship between care recipient behavioral problems and carer depressive symptoms (Huang, 2004; Mausbach et al., 2006, 2012). The effect of behavioral problems on carer depressive symptoms was no longer significant when avoidance coping was accounted for. Significant findings were also reported by Morano (2003), where emotion-focused coping (managing the emotional responses to the stresses) moderated the effect of problematic behavior on carer depressive symptoms. Mastery, self-efficacy, and resilience were examined as specific coping responses in relation to depressive and anxiety symptoms in four studies (Mausbach et al., 2007, 2012; O’Rourke et al., 2010; Pioli, 2010). Mausbach and colleagues (2012) found that mastery and self-efficacy were inversely associated with depressive symptoms for spousal carers, after controlling for role overload. Both Mausbach and colleagues (2007) and Pioli (2010) reported a significant main effect for mastery, where increases in mastery resulted in decreases in spousal carer depressive symptoms. In addition, both Mausbach and colleagues (2007) and Pioli (2010) found a significant interaction for mastery and role overload with carer depressive symptoms, where there was a significant relationship between role overload and spousal carer depressive symptoms when mastery was low. Pioli (2010) also found that mastery was a significant moderator of the relationship between role overload and carer anxiety symptoms. Lastly, O’Rourke and colleagues (2010) examined whether psychological resilience played a protective role against depressive symptoms for spousal carers. O’Rourke and colleagues (2010) found that carers who reported higher levels of perceived control (i.e., the belief one can affect the conditions of life) and challenge (i.e., the belief that challenges provide opportunities to increase skills and self-knowledge) at baseline reported significantly lower levels of depressive symptoms 1 year later. Both formal and informal social support had a positive impact on carers’ depressive symptoms (Clay et al., 2008; Huang, 2004). Clay and colleagues (2008) examined the impact of informal social support on adult–child carers’ depressive symptoms. Clay and colleagues (2008) demonstrated that satisfaction with support was a significant predictor of fewer depressive symptoms, after controlling for the number of social supports available to the carer. Huang (2004) examined the influence of formal social support in the form of a paid helper. A significant negative correlation was found between carer depressive symptoms and having a paid helper, where carers with a paid helper experienced fewer depressive symptoms (Huang, 2004). The influence of personality characteristics on carer depressive symptoms was reported in two studies (Gallant & Connell, 2003; Hayslip et al., 2008). Gallant and Connell (2003) examined neuroticism in isolation, and found that higher levels of neuroticism were significantly related to higher levels of depressive symptoms for their sample of spousal carers. In contrast, Hayslip and colleagues (2008) included a more comprehensive representation of personality with the examination of the role of the five factor personality traits (i.e., neuroticism, openness, agreeability, extraversion, conscientiousness). Hayslip and colleagues (2008) demonstrated that collectively the personality traits significantly predicted increased depressed mood for both spousal and adult–child carers. When considered in isolation, extraversion was the only personality trait that uniquely predicted depressed mood, where more introverted carers experienced more depressed mood (Hayslip et al., 2008). The effect of existing symptoms on carers’ current experience of anxiety and depressive symptoms was examined in two studies (Hayslip et al., 2008; Joling et al., 2015). Joling and colleagues (2015) was the only study to investigate the predictors of depressive and anxiety disorders for spousal carers over time. They found that sub-threshold depressive symptoms at baseline predicted later onset of a depressive or anxiety disorder (Joling et al., 2015). Hayslip and colleagues (2008) explored the relationship between anxiety about ageing and carer depressive symptoms, sampling both adult–child carers and spousal carers. Anxiety about aging uniquely predicted depressed mood, indicating that carers who were more anxious about their aging experienced more depressive symptoms (Hayslip et al., 2008). Dyadic Relationship Factors Six studies investigated how the relationship between the carer and care recipient impacted carers’ experiences of depressive symptomatology (Beeson, Horton-Deutsch, Farran, & Neundorfer, 2000; Braun, Mura, Peter-Wight, Hornung, & Scholz, 2010; Chun et al., 2007; Fauth et al., 2012; Luchsinger et al., 2015; Rankin et al., 2001). The type of relationship between the carer and care recipient (i.e., spousal or adult–child) was examined in two studies (Chun et al., 2007; Luchsinger et al., 2015). Chun and colleagues (2007) found that adult–child carers reported higher depressive symptoms compared with spousal carers. However, Luchsinger and colleagues (2015) failed to find a significant relationship between carer relationship and depressive symptoms. The remaining four studies examined the role of relationship quality, finding that poor relationship quality was consistently linked to greater depressive symptoms for carers (Beeson et al., 2000; Braun et al., 2010; Fauth et al., 2012; Rankin et al., 2001). Braun and colleagues (2010) investigated the relationship between caregiver depression and quality of marital communication, and found carer depressive symptoms were significantly negatively associated with the care recipients’ positive communication. Beeson and colleagues (2000) found significant positive correlations between spousal carer depressive symptoms and relationship factors including poor quality of relationships and relational deprivation. Relational deprivation was conceptualized as the loss of exchange of intimacy, goals, and social activities shared within the relationship. The researchers found that greater depressive symptoms were related to greater feelings of relational deprivation and poorer relationship quality for carers. In addition, Fauth and colleagues (2012) found that spousal carers who reported higher levels of closeness within their relationship reported significantly lower depressive symptoms. Lastly, Rankin and colleagues (2001) classified spousal carers by their depression status (experiencing depression or not) and compared their perceptions of relationship quality. They found that the subsample of depressed spousal carers reported significantly lower levels of family satisfaction and marital cohesion. Discussion The aim of this systematic review was to investigate the factors that are associated with depression and anxiety for family carers of PWD. This study reviewed 26 studies that examined a wide range of factors in relation to carer depression and/or anxiety, including demographic factors, dementia characteristics, carer psychological and social factors, and factors related to the dyadic relationship. Psychological factors received the most attention in the studies, most notably carer burden (Epstein-Lubow et al., 2008; Morano, 2003; Rankin et al., 2001; Williams, 2011), coping styles (Huang, 2004; Mausbach et al., 2006, 2012; Morano, 2003), and specific coping responses such as self-efficacy (Mausbach et al., 2007, 2012; O’Rourke et al., 2010; Pioli, 2010). Dementia characteristics were also well represented, with studies consistently reporting on the role of problematic behaviors exhibited by care recipients (Chun et al., 2007; Huang, 2004; Mausbach et al., 2006, 2012; Romero-Moreno et al., 2014). Although there were a wide range of risk factors that were identified, there were some prominent factors that were consistently associated with depression across studies. Female caregivers were more at risk for depression (Adams et al., 2002; Pöysti et al., 2012; Rankin et al., 2001). Care recipient factors such as severity of dementia problematic behaviors were also found to be important risk factors for depressive (Huang, 2004; Mausbach et al., 2006, 2012) and anxiety (Chun et al., 2007) symptoms among carers. It is important to understand the demographic and dementia – specific factors that place family carers at risk of depression and anxiety, so that at risk populations can be targeted for both prevention and intervention program in mental health. In terms of psychological factors, coping strategies were found to be strongly related to depressive symptoms. Using avoidant coping strategies was found to be associated with higher carer depressive symptoms (Huang, 2004; Mausbach et al., 2006, 2012), whereas managing emotional responses to stress was associated with lower levels of carer depressive symptoms (Morano, 2003). Further, higher levels of mastery, self-efficacy, and resilience were related to lower levels of depressive (Mausbach et al., 2007, 2012; Pioli, 2010) and anxiety symptoms (Pioli, 2010). These findings add to the existing understanding of depression and anxiety among dementia family caregivers by clearly identifying the areas to target to strengthen the mental health of family carers. Some of the key risk factors identified in this review are also prominent risk factors for carer stress and burden (Etters et al., 2008; van der Lee, Bakker, Duivenvoorden, & Dröes, 2015; O’Dwyer, Moyle, Zimmer-Gembeck, & De Leo, 2016). However, the current findings highlighted some risk factors for depressive symptoms which are not major risk factors for stress and burden. For example, increased activity restriction (Mausbach et al., 2008, 2012; Romero-Moreno et al., 2014), where carers were restricted in their social activities, were related to depressive and anxiety symptoms, but not burden. Relationship type and quality were important factors associated with depressive symptoms. An interesting finding was that adult–child carers, rather than spousal carers, were more at risk of depressive symptoms and so should be specifically targeted in mental health programs. Enhancing closeness and intimacy as well as enhancing the quality of the relationship should all be targets in preventing and treating depression among family carers. Although this review highlights some of the prominent risk factors for dementia carers’ depressive symptoms, there are several important limitations within the currently available evidence. The studies were characterized by a lack of depth and precision. There was little consideration within the studies of the interplay between multiple factors. For example, few studies examined whether the combination of carers’ psychological factors and care recipient dementia characteristics made carers particularly susceptible to depression and anxiety symptoms. Due to the lack of research, no interpretations can be made about whether there are specific pathways or critical factors that accumulate to result in depressive and anxiety symptoms. The use of cross-sectional designs in the majority of studies also limits the conclusions that can be drawn about the potential causes of carers depressive and anxiety symptoms and the changes over time. The use of cross-sectional designs also limits the ability to examine important mediating factors that may contribute to the understanding of the ways other factors interact with caregivers’ experiences of depression and anxiety. Prospective studies tracking carers across their caregiving experiences would provide greater insight into whether there are periods of risk where they are more vulnerable to developing depression or anxiety, and what critical factors increase family carers’ vulnerability to depression and anxiety at specific points of time. Studies need to consider the impact of the length of time providing care on family carers’ depressive and anxiety symptoms. Within the included studies, there was limited detail about the length of time the carers had been providing care. In addition, studies need to account for carers’ experiences of depressive and anxiety symptoms prior to becoming a carer, and how this may contribute to the progression and severity of depression and anxiety across the caregiving experience. Joling and colleagues (2015) was the only study included in the review to investigate the impact of existing sub-threshold symptoms on the future development of diagnosed depression and anxiety. The studies identified within the review showed variability in the measures used to assess depressive and/or anxiety symptoms. Scales represented in the studies differed on the nature of the depressive and anxiety symptoms that were evaluated, the time frame specified, the level of endorsement of symptoms, and the meaning of the final score. For example, the Centre for Epidemiological Studies Depression Scale (Radloff, 1977) used a total of 20 items to assess depressive symptomatology, including depressed affect, positive affect, somatic difficulties, retarded activity, and interpersonal relationship problems. Participants were asked to rely on the time frame of “the past week” and rate the items according to the frequency of the symptom (ranging from “rarely or none of the time, <1 day” to “most or all of the time, 5–7 days”) (Radloff, 1977). In contrast, the Geriatric Depression Scale (Sheikh & Yesavage, 1986; Yesavage et al., 1982) focused exclusively on the affective and cognitive symptoms of depression with the 30 items, including apathy, sadness, crying, and thoughts of helplessness, worthlessness, guilt, and hopelessness. Items are endorsed for their “current” presence (yes/no) (Sheikh & Yesavage, 1986; Yesavage et al., 1982). This inconsistency and variability in symptoms and the ways in which they were assessed (including severity and frequency) limits comparability of results. While there is less variability in the scales used to assess anxiety symptoms, this is not because of greater consistency of measures but rather a lack of studies that examined carers’ experiences of anxiety. Only three of the studies examined anxiety symptoms, and two scales were used to assess the anxiety symptoms (Chun et al., 2007; Joling et al., 2015; Pioli, 2010). The use of appropriate scales that are valid and reliable in their assessment of depressive and anxiety symptoms will ensure that findings generated from future research can be meaningfully compared. Only one study utilized a clinical interview with strict diagnostic criteria to assess whether the participant was experiencing a depressive or anxiety disorder (Joling et al., 2015). While other scales provided cutoffs for the final score to suggest risk of a clinical disorder or severity of the depression or anxiety (i.e., mild, moderate, or severe), these did not map onto diagnostic criteria. Future research investigating the experience of depression and anxiety for family carers would benefit from the inclusion of a clinical interview such as the Mini-International Neuropsychiatric Interview (Sheehan et al., 1998) or Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (First, Williams, Karg, & Spitzer, 2015), to ensure appropriate assessment of depression and anxiety as clinical disorders. Furthermore, examination of anxiety and depression within the same sample (see Joling et al., 2015) would provide greater insight into how anxiety and depression manifest for family carers of PWD. For example, it is important to examine whether there is an overlap of symptoms and comorbidity of disorders (Joling et al., 2010) and whether there are common risk factors that contribute to both disorders. Examination of depression and anxiety as clinical disorders within research has important clinical implications. Clinicians interacting with both the PWD and their family carers need to be able to accurately identify those family carers who are at risk of, or are currently experiencing, depression and anxiety. In order to achieve this, clinicians require an understanding of how depression and anxiety manifest for family carers, as well as how key risk factors contribute to the development or exacerbation of the depression and anxiety. Conclusion This review examined those factors associated with depression and anxiety for family carers of PWD. Findings indicated depressive and anxiety symptoms are related to a range of carer demographic factors, dementia characteristics, carer psychological and social factors, and dyadic relationship factors. However, a lack of measurement precision and a reliance on cross-sectional studies limits our understanding of exactly how depression and anxiety progress during the caregiving experience and the factors that increase family carers’ risk of developing depression and anxiety. The implications for prevention and intervention programs for depression and anxiety are discussed, as well as suggestions for future research to improve the quality of research in this area. Supplementary Data Supplementary data are available at The Gerontologist online. Funding None reported. Conflict of Interest None reported. References Adams , B. , Aranda , M. P. , Kemp , B. , & Takagi , K . ( 2002 ). Ethnic and gender differences in distress among Anglo American, African American, Japanese American, and Mexican American spousal caregivers of persons with dementia . 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The GerontologistOxford University Press

Published: Jun 6, 2018

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