---
title: "Caregiver burden, depression, anxiety, and quality of life among caregivers of people with severe"
id: "plos-one-20-caregiver-burden-and-its-association-with-depression-anxiety-and-quality-of"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-20-caregiver-burden-and-its-association-with-depression-anxiety-and-quality-of"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355872"
published_at: "2026-08-13T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Caregiver burden, depression, anxiety, and quality of life among caregivers of people with severe
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-20-caregiver-burden-and-its-association-with-depression-anxiety-and-quality-of
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0355872)
- **Published At:** 2026-08-13T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This cross-sectional study surveyed 120 family caregivers of individuals with **Severe Persistent Mental Illness (SPMI)** attending a psychiatry outpatient clinic at King Saud University Medical City in Riyadh between February and April 2024. - Validated Arabic instruments were used: the abridged Zarit Burden Interview (ZBI) for **caregiver burden**, Patient Health Questionnaire-9 (PHQ-9) for **depression**, Generalized Anxiety Disorder-7 (GAD-7) for **anxiety**, and WHOQOL-BREF for **quality of life (QoL)**. - Caregiver burden correlated positively with both depression and anxiety scores (p < 0.001). - Higher burden was observed among female caregivers (p = 0.04), caregivers who lived with the patient (p = 0.002), and when the caregiver perceived the patient’s illness as more severe (p = 0.001). - Spouses and children reported significantly greater burden than other caregiver relationships (p = 0.036). - In multivariable analyses, caregiver **anxiety** and perceived illness severity were independently associated with higher burden. - Depressive and anxiety symptoms were independently associated with poorer **quality of life**. - Caregiver burden showed a significant negative correlation with the physical QoL domain (p < 0.001) and the psychological QoL domain (p = 0.013). - The authors conclude that caregivers of people with SPMI in Saudi Arabia face elevated mental health challenges that negatively affect QoL, and they call for targeted support interventions addressing anxiety, depression, and burdens related to severe mental illness—especially for those living with or closely related to patients. - Data supporting the study are publicly available in a Zenodo repository and the work was funded by King Saud University (ORF-2026-2176).
## Clinical Analysis & Structured Key Points
Caregiver burden and its association with depression, anxiety, and quality of life among caregivers of individuals with severe persistent mental illness in Saudi Arabia: A cross-sectional study | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Reader Comments Figures Figures Abstract Caregivers of patients with Severe Persistent Mental Illness (SPMI) face tremendous challenges. They often experience elevated levels of burden, depression, and anxiety. These factors negatively impact their quality of life (QoL). However, few studies have examined caregiver burden and its psychological effects in Saudi Arabia. This study aims to assess caregiver burden in relation to socio-demographic characteristics and its correlation with depression, anxiety, and QoL. The study tool consisted of validated questionnaire, including the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), abridged Arabic version of the Zarit Burden Interview (ZBI), and the World Health Organization Quality of Life-Brief Version (WHOQOL-BREF). A cross-sectional convenience sample of 120 participants was recruited from the Psychiatry Outpatient Clinics at King Saud University Medical City in Riyadh, Saudi Arabia. Our results showed a significant positive correlation between caregiver burden and depression and anxiety scores (p < 0.001). Moreover, significantly higher burden levels were found among female caregivers and those residing with patients, p = 0.04 and p = 0.002, respectively. Additionally, the severity of mental illness was also associated with an increased burden level (p = 0.001). Notably, spouses and children reported significantly higher burden levels (p = 0.036). In multivariable analyses, caregiver anxiety and perceived severity of the patient’s mental illness were independently associated with higher caregiver burden, while depressive and anxiety symptoms were independently associated with poorer quality of life.Furthermore, a significant negative correlation was found between caregiver burden and the physical and psychological QoL domains (p < 0.001 and p = 0.013, respectively). Collectively, our findings highlight the mental health challenges faced by caregivers of individuals with SPMI in Saudi Arabia, which negatively impact their QoL. Consequently, these findings substantiate the urgent need for targeted support interventions, particularly those addressing caregiver anxiety, depression, and the challenges associated with severe mental illness, especially for caregivers who live with or care for individuals with SPMI. Citation: Albrekkan F, Alenezi S, Ghesheyan A, Almousa MS, Alabduljabbar MA, Alkanhal IM, et al. (2026) Caregiver burden and its association with depression, anxiety, and quality of life among caregivers of individuals with severe persistent mental illness in Saudi Arabia: A cross-sectional study. PLoS One 21(8): e0355872. https://doi.org/10.1371/journal.pone.0355872 Editor: Madson Alan Maximiano-Barreto, University of Sao Paulo, BRAZIL Received: March 11, 2026; Accepted: July 27, 2026; Published: August 13, 2026 Copyright: © 2026 Albrekkan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The anonymized dataset underlying the results presented in this study, together with the data dictionary, has been deposited in Zenodo and is publicly available at: https://doi.org/10.5281/zenodo.20643370 . All relevant data necessary to replicate the study findings are available through the repository. Funding: This research was funded by ongoing research funding program, (ORF-2026-2176), King Saud University, Riyadh, Saudi Arabia. FA confirmed the recipient of this funding. However, the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: NO authors have competing interests. 1. Introduction Mental illness is a health condition that can cause changes in behavior, thinking, emotions, or a combination of these [ 1 ]. The term “Severe and Persistent Mental Illness" (SPMI) is commonly used to describe a group of mental disorders that typically emerge in early adulthood and significantly affect family relationships, education, work productivity, and social functioning throughout a person’s life [ 2 ]. However, there is no universally accepted definition of Severe and Persistent Mental Illness (SPMI) as there is significant variation in how its core dimensions—diagnosis, disability, and duration—are defined and operationalized. This inconsistency stems from differing contexts and purposes among researchers, policymakers, and clinicians, making it challenging to establish a standardized definition [ 3 ]. These illnesses include, but are not limited to, schizophrenia, bipolar disorder, major depressive disorder, personality disorders, persistent depressive disorder, obsessive-compulsive disorder, autism spectrum disorder, and attention-deficit hyperactivity disorder [ 3 ]. Mental illness is prevalent worldwide. In 2021, one in seven individuals, or 1.1 billion people, had a mental illness, with anxiety and depressive disorders being the most prevalent [ 4 ]. The Saudi National Mental Health Survey (SNMHS), part of the World Health Organization (WHO) World Mental Health (WMH) Surveys initiative, was one of the first national studies to establish the prevalence of mental illness in Saudi Arabia. A total of 4004 interviews were completed, of which 1981 respondents were included in the study. The study found that over 20.2% of respondents had some form of mental illness, with anxiety disorders being the most prevalent (12.3%). Mood disorders were present in 6.8% of respondents. Regarding individual disorders, social phobia was the most common, followed by major depressive disorder and separation anxiety disorder (4.2%, 3.8%, and 3.7%, respectively) [ 5 ]. The phrase caregiver burden refers to the complex stress experienced by individuals providing ongoing care to family members or loved ones [ 6 ]. Quality of Life (QoL) is the perception of one’s position in life in relation to goals, expectations, standards, and concerns within one’s cultural and value systems [ 7 ]. Several studies have shown that caregivers are at a higher risk of developing mental illnesses than the general population [ 8 , 9 ]. Caregivers are also more likely to experience psychological, social, and physical hardship [ 10 ]. A Brazilian study reinforced this perspective and found that caregivers have a high prevalence of depressive disorders [ 11 ]. Another study found that caregivers face profound psychological stress in addition to increased depression and anxiety, with elevated levels of caregiver burden [ 12 ]. Several socio-demographic factors, such as living with the patient [ 11 ] and having a low monthly income [ 13 ], were associated with increased burden levels. While systematic reviews have highlighted the multidimensional impact of caregiving, including increased burden, emotional distress, and reduced well-being among family members of individuals with severe mental illness [ 10 , 12 ], evidence from Saudi Arabia remains limited. Existing local research has primarily focused on specific aspects of the caregiving experience, such as QoL among caregivers of individuals with mental illness [ 14 ]. Consequently, a more comprehensive understanding of caregiver burden and its relationship with depression, anxiety, and QoL among caregivers of individuals with SPMI in Saudi Arabia remains scarce. Given the cultural and social factors that may influence caregiving experiences in Saudi Arabia, further research is needed to better understand these interrelated outcomes. Therefore, this study aimed to examine caregiver burden and its association with depression, anxiety, and QoL among caregivers of individuals with SPMI in Saudi Arabia. By simultaneously examining caregiver burden, depression, anxiety, and QoL among caregivers of individuals with SPMI in Saudi Arabia, this study addresses an important gap in the regional literature and provides evidence to inform culturally appropriate caregiver support services and interventions. 2. Materials and methods 2.1 Design and ethical aspects This is a cross-sectional study that was conducted at one of the tertiary hospital, King Saud University Medical City (KSUMC) psychiatry outpatient clinic in Riyadh, Saudi Arabia, from February 2024 to April 2024. For the purpose of this study, a caregiver was defined as an adult family member or significant other who provided unpaid physical, emotional, supervisory, or practical support to an individual with SPMI and who was involved in the patient’s care on a regular basis. Eligible participants were required to be aged 18 years or older and able to read and understand Arabic. Diagnosis include schizophrenia, bipolar disorder, major depressive disorder, personality disorders, persistent depressive disorder, and obsessive-compulsive disorder. Additionally, we included caregivers of patients with neurodevelopmental disorders such as autism and attention-deficit hyperactivity disorder (ADHD) in Saudi Arabia. These disorders were grouped under the broader category of SPMI because they are chronic conditions associated with substantial functional impairment, long-term care needs, and significant caregiving demands. To explore potential differences related to diagnosis, additional analyses were conducted according to diagnostic category and are reported in the Results section. Our exclusion criteria were caregivers of patients with neurocognitive disorders such as Alzheimer’s disease, which has been extensively studied in the literature. The nature and purpose of the study, the principal investigator’s contact information, and an explanation of the confidentiality and data anonymity policy were provided. Before participating in the survey, the participants provided informed consent. After providing consent, the participants accessed the study survey, which took an average of 15–20 minutes to complete. The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of the College of Medicine, King Saud University (Research Project No. E-24–8487, dated 31/01/2024). Responses were collected anonymously, and no personally identifiable information was obtained. Data were stored securely and accessed only by the research team. 2.2. Sample We conducted a pilot study to estimate our sample size using a single-mean formula by selecting the Arabic version of the Zarit Burden Interview scale with the highest available standard deviation. The standard deviation was 7.37. For the precision of the estimate (d), we chose a one-difference score for the total ZBI-A score. Zα/2 was 1.96 for a 95% confidence level. This led us to calculate the sample size as follows: (1.96) 2 ×(7.37) 2 /(1) 2 =3.841×54.32/1=208.66≈209 𝑝𝑎𝑟𝑡𝑖𝑐𝑖𝑝𝑎𝑛𝑡𝑠 We estimated that the non-response rate would be 20%; therefore, we added this estimate to the sample size: 209 + 41.8 ≈ 251. Considering that the standard deviations for the remaining scales were lower than those of the ZBI-A, the required sample size for these instruments would be less than 209 participants. However, we encountered several significant challenges that impacted our ability to meet the initially calculated sample size of 251 participants, resulting in a sample size of 120 participants. These difficulties arise primarily from niche population challenges, limited cooperation from relevant organizations, and time constraints. Moreover, we conducted a convenience sampling technique in which we interviewed every attending caregiver from the outpatient clinics at KSUMC. 2.3. Procedure Caregivers who were eligible and attended the psychiatric outpatient clinic during the study period were approached consecutively by members of the research team, who explained the study’s objectives. Those who met the eligibility criteria and agreed to participate were invited to complete a survey. This survey could be done either electronically via a secure link or in person during their clinic visit. Participation was entirely voluntary, and no incentives were offered. Recruitment continued throughout the study period until no additional eligible caregivers were available to enroll. The primary outcome variables (effects) we evaluated are as follows: Caregiver burden includes the time spent on oneself, role strain, anger, negative relationships, emotional strain, health-related strain, lack of privacy, social life, loss of control, decision uncertainty, perceived shortcomings, and self-efficacy. Caregivers’ QoL scores encompassed four domains: physical health, psychological health, social relationships, and environment. Depression scores. Anxiety scores. The main assessed exposure variables (causes and risk factors) were as follows: Caregivers’ characteristics included sex, age, city of residence, marital status, education level, living with a person with mental illness in the same household, and monthly income. Characteristics of people with mental illness: sex, age group, relationship with caregivers, type of mental disorder, and type and quality of support 2.4. Measures/instruments We conducted a survey across five sections. The first section consisted of socio-demographic questions. In the second section, we used the ZBI-A, a widely used tool comprising 12 items to assess the level of burden in caregivers of patients with different morbidities [ 6 ]. Items were rated on a 5-point Likert scale ranging from 0 (never) to 4 (almost always), with a higher score representing a higher sense of burden. The scale scores ranged from 0 to 48. It was initially written in English and translated into Arabic by Bachner et al. and was found to be valid and reliable [ 15 ]. The World Health Organization Quality of Life Questionnaire (WHOQOL-BREF), an abbreviated and validated version of the WHOQOL-100 assessment tool, is used in the third section. The WHOQOL-BREF was developed to evaluate four QoL domains: physical health (seven items), psychological health (six items), social relationships (three items), and environment (eight items). It consists of 26 items, with 24 items divided into four domains and two additional general items on overall QoL and general health. Each item is rated on a 5-point Likert scale, where a higher score indicates better QoL within a particular domain [ 16 , 17 ]. The Arabic version of the WHOQOL-BREF has demonstrated high reliability and validity indices [ 14 ]. In the fourth section, we used the Generalized Anxiety Disorder-7 (GAD-7) scale, a widely used tool for assessing the severity of anxiety symptoms. It consists of seven items scored from 0 to 3, with total scores ranging from 0 to 21. Higher scores indicated more severe anxiety. The GAD-7 has been demonstrated to be reliable and valid in various populations [ 18 ]. The Arabic version of the GAD-7 demonstrated reasonable reliability [ 19 ]. In the fifth section, we utilized the Patient Health Questionnaire-9 (PHQ-9), a validated tool used in various populations, and conducted studies in different languages to assess depression severity. Items were scored from 0 to 3, ranging from 0 to 27, with a cutoff value of 10 [ 20 ]. The Arabic version has good internal consistency with a Cronbach’s alpha of 0.857 [ 19 ]. 2.5. Statistical analysis In the data analysis section, we employed a range of statistical methods to examine the collected data using SPSS version 21. The data distribution and central trends are summarized. We applied Student’s t-test for independent samples to compare the differences between the two independent groups. For comparisons among more than two groups, we used Analysis of Variance (ANOVA), which allowed us to assess the statistical significance of differences across multiple categories, such as income levels or different types of relationships with the patient (e.g., spouses, children, or uncles). Prior to conducting parametric analyses, the assumptions of normality and homogeneity of variance were evaluated. Normality of continuous variables was assessed using the Kolmogorov–Smirnov test and visual inspection of histograms. Homogeneity of variances was assessed using Levene’s test for independent-samples t-tests and ANOVA. For multivariable linear regression, multicollinearity was evaluated using tolerance statistics and variance inflation factor (VIF) values. Residual plots and observed-versus-predicted distributions were examined to assess model fit. Multivariable linear regression analyses were performed to identify factors independently associated with caregiver burden and caregivers’ quality of life. Separate models were constructed using the Zarit Burden Interview (ZBI) score and the overall Quality of Life (QoL) score as dependent variables. Candidate predictor variables were selected based on their clinical relevance, evidence from the literature, and findings from the preliminary bivariate analyses. An exploratory iterative modelling approach was used to develop parsimonious final models while evaluating multicollinearity, model fit, and clinical interpretability. The final caregiver burden and quality-of-life models included six and eight predictors, respectively, representing approximately 20 and 15 observations per predictor, indicating an adequate participant-to-predictor ratio for the multivariable analyses. The associations between the independent predictor variables and the outcomes were expressed as un-standardized beta coefficients with corresponding 95% confidence intervals. Variables demonstrating substantial conceptual or statistical redundancy were excluded where appropriate to avoid collinearity inflation. A two-sided p-value < 0.05 was considered statistically significant. 3. Results Caregiver burden by sociodemographic characteristics Descriptive statistics for the Zarit Burden Interview (ZBI) by socio-demographic characteristics of caregivers are shown in Table 1 . When caregiver burden was analyzed by sex, females had a higher mean total ZBI score (M = 15.74, SD = 9.76). Males had a lower mean score (M = 12.05, SD = 9.72). Divorced caregivers had the highest mean total ZBI score (M = 18.78, SD = 10.50). Download: PNG larger image TIFF original image Table 1. Descriptive statistics of Zarit Burden Interview scores (ZBI) by caregiver socio-demographic characteristics. https://doi.org/10.1371/journal.pone.0355872.t001 Regarding educational level, caregivers with a middle school education reported the lowest burden (M = 5.50, SD = 4.95). However, it should be noted that this group had a small sample size (n = 2), which may limit the reliability of this result. Caregivers with a high school education had a mean ZBI total score of 9.42 (SD = 6.13), whereas those with higher education had a mean total ZBI score of 14.81 (SD = 10.25). Similarly, when examining monthly income, caregivers earning less than 5000 SR had a mean burden score of 13.39 (SD = 8.99), whereas those earning more than 20000 SR had the highest mean total ZBI score (M = 15.50, SD = 11.53). In addition, mean total ZBI scores also differed by living arrangement. Caregivers who did not live with their patients had lower mean total ZBI scores (M = 9.73, SD = 7.81) than those who did (M = 15.61, SD = 10.19). Descriptive statistics for the Zarit Burden Interview (ZBI) by patients’ socio-demographic characteristics were illustrated in Table 2 . Regarding patient age, the largest age category was younger than 18 years (
## Related Clinical Research

- [Dementia-Related Violence in Memory Care: Repeated Resident-to-Resident Attacks Despite Warnings](https://medichelpline.com/clinical-feed/kff-health-news-0-violence-repeatedly-erupts-at-dementia-care-facilities-despite-warnings.md)
- [Digital eMPower program reduces anxiety and depression in adults with chronic conditions: randomiz](https://medichelpline.com/clinical-feed/plos-medicine-0-effect-of-a-digital-intervention-on-mental-health-symptoms-in-adults-with.md)
- [Psychometric evaluation of the CISS-SF: validity, reliability, and factor structure](https://medichelpline.com/clinical-feed/plos-one-14-psychometric-properties-of-a-short-form-for-the-coping-inventory-for-stressful.md)
- [Nurse Practitioner Trainees Face Clinical Mentor Shortage and Preceptor Challenges](https://medichelpline.com/clinical-feed/stat-news-3-nurse-practitioner-trainees-find-themselves-stymied-by-shortage-of-clinical.md)
- [Polygenic and familial influences on antidepressant continuation, switching, discontinuation and a](https://medichelpline.com/clinical-feed/medrxiv-13-polygenic-and-familial-contributions-to-antidepressant-continuation-switching.md)

## Navigation
- [← Back to General Feed](https://medichelpline.com/clinical-feed/general.md)
- [← All Clinical Specialties](https://medichelpline.com/clinical-feed.md)
## Medical & Regulatory Disclaimer

> [!CAUTION]
> MedicHelpline content is structured for research, educational, and professional discovery purposes. It does not constitute individual medical advice, clinical diagnosis, or treatment recommendations.
> Always verify dosing, contraindications, and regulatory alerts against official product labeling and primary regulatory sources before clinical decision-making.