Perceived Social Support Mediating Caregiver Burden and Mental Health in Schizophrenia Caregivers

Abstract

Schizophrenia is a severe, chronic mental disorder that imposes a substantial burden on family members, and this burden is strongly correlated with caregivers’ increased levels of anxiety and depression. Conversely, perceived social support functions as a critical coping resource, thereby effectively moderating stress and facilitating better psychological adjustment. This quantitative study tested the mediating hypothesis that perceived social support accounts for the relationship between caregiver burden and these negative psychological outcomes. This study adopted a cross-sectional design and convenience sampling to recruit 393 patients with schizophrenia and their primary family caregivers in China. The data collected included demographic information, caregiver burden, anxiety and depression, and perceived social support levels. Statistical analyses included ANOVA, correlation analysis, and hierarchical regression analysis. The results showed that caregiver burden was positively correlated with both anxiety and depression, and that perceived social support played a partial mediating role in this relationship. The mediating effect of perceived social support was particularly strong in mitigating the association between burden and depression. The findings indicate that perceived social support is vital in alleviating psychological distress among these caregivers, suggesting that targeted interventions focusing on strengthening social support networks can effectively improve the mental health status of family caregivers of patients with schizophrenia.

Keywords

schizophrenia caregiver burden perceived social support anxiety depression mediating effect

Introduction

Schizophrenia is a severe, long-term mental illness characterized by a chronic course, frequent relapses, and a high rate of recurrence and disability (McCutcheon et al., 2020). Based on a comprehensive survey across 31 Chinese provinces, the lifetime prevalence of schizophrenia was found to be 0.6% (Huang et al., 2019). Currently, most hospitalized patients with schizophrenia are admitted during acute episodes, and during the relatively stable phases of the illness, care is primarily home-based (Armijo et al., 2013). The patient’s spouse, parents, children, and other relatives serve as the main caregivers, taking responsibility for daily medication management, personal care, and medical expenses (Reinhard et al., 2008).

Many studies have shown that caregivers of patients with schizophrenia experience a greater burden compared to those caring for patients with other chronic illnesses (Awad & Voruganti, 2008). Long-term caregiving places a substantial burden on family caregivers, which is associated with adverse psychological outcomes, particularly anxiety and depression (Khatimah et al., 2022; Rahmani et al., 2022).

A previous study reported that 24.6% of caregivers experienced moderate to severe anxiety and 38.5% had mild anxiety, while 61.5% were classified as having moderate to severe depression according to the Hamilton Anxiety and Depression Rating Scales (Nasir et al., 2022). In addition to caregiver burden, demographic variables such as gender, as well as social factors, also play a significant role in influencing caregivers’ anxiety and depressive symptoms (Sharma et al., 2016). Previous research consistently indicates that female caregivers generally report higher levels of burden and frustration compared to their male counterparts when providing care for relatives with mental illness (Ascher-Svanum & Sobel, 1989; Sharma et al., 2016). Furthermore, previous studies have suggested that perceived social support may play a protective role in the mental health of family caregivers of patients with schizophrenia (Lok & Bademli, 2021; Yen & Lundeen, 2006).

Perceived social support refers to an individual’s subjective evaluation of the quantity and quality of support that may be available through social relationships and interactions, including support from family, friends, and significant others (J. Wang et al., 2018; Zimet et al., 1988). Compared with received or objective social support, perceived social support reflects an individual’s appraisal of the adequacy and quality of support from a subjective perspective, and is therefore one of the most commonly used indicators in the measurement of social support (Dour et al., 2014). Studies have established that higher levels of perceived social support are associated with lower severity of anxiety and depression among caregivers (Gutierrez-Sanchez et al., 2023; Priego-Cubero et al., 2023). Previous studies have highlighted the mediating role of perceived social support in caregiving-related outcomes among family caregivers of patients with schizophrenia. Specifically, perceived social support has been found to partially mediate the relationship between internalized stigma and caregiving burden (Guan et al., 2022). In addition, it mediates the association between caregiving burden and positive caregiving experiences and may operate as part of a serial mediation pathway with hope (Guan et al., 2023). Furthermore, perceived social support has also been reported to mediate the relationship between the meaning of caregiving and caregiver depression (Yen & Lundeen, 2006). In addition, research indicates that informal social support provided by family members helps to alleviate caregiver burden and enhance coping abilities (Shiba et al., 2016).

Despite extensive research on the burden and psychological health issues of family caregivers for individuals with schizophrenia, studies focusing specifically on the mediating function of perceived social support in the relationship between caregiver burden and anxiety and depression are notably lacking. Therefore, understanding the impact of perceived social support in this context is of considerable significance. This study aims to test the hypothesis that perceived social support mediates the relationship between caregiver burden and psychological distress (anxiety and depression) among family caregivers of schizophrenia patients, with the goal of developing specific recommendations to alleviate psychological symptoms.

Participants and Methods

Patient and Public Involvement

This study primarily focuses on investigating the caregiving burden and mental health status experienced by family caregivers of patients with schizophrenia. As a quantitative cross-sectional survey, patients or the public were not involved in defining the research questions, selecting outcomes, or formally participating in the study design, management, data analysis, or interpretation.

However, the caregivers themselves are the focus of this study, and their lived experiences and feedback constitute the entire basis of our data. During the study, we strictly adhered to ethical guidelines: prior to their inclusion in the study, all primary family caregivers received comprehensive information regarding the research objectives and procedures, subsequently providing written informed consent to ensure the preservation of their autonomy and voluntary participation. Individuals with lived experience were not offered authorship of this paper.

Participants Recruitment

This study was conducted from August to December 2023 in two urban districts in China, in collaboration with local mental health centers. Convenience sampling was utilized to recruit eligible participants from the population of patients with schizophrenia managed by the selected centers. For each patient, one primary family caregiver was identified and invited to participate in the survey. The inclusion criteria included (1) participants diagnosed with schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; Joyce-Beaulieu & Sulkowski, 2016); (2) the caregiver was a family member of the patient and lived with the patient; (3) the caregiver was over 18 years old and had been caring for the patient for more than 3 months; (4) the caregiver had independent reading and communication abilities and voluntarily agreed to participate in the study. The exclusion criteria included (1) family caregivers who had mental or psychological illnesses; (2) families that had recently experienced major traumatic or life events.

A total of 413 questionnaires were distributed, of which 393 were valid, yielding an effective response rate of 95.2%. All questionnaires were completed anonymously. Data cleaning was conducted after collection, and questionnaires with incomplete responses or logical inconsistencies were excluded.

This study was approved by the Medical Research Ethics Committee of the School of Public Health, Fudan University (IRB00002408 and FWA00002399). Prior to the study, all participants and their family members received complete disclosure concerning the study’s aims and procedures, and written informed consent was subsequently secured from both parties.

Measurement

The questionnaire used in this study consisted of four sections: the General Information Questionnaire, the Caregiver Burden Inventory (CBI), the Multidimensional Scale of Perceived Social Support (MSPSS), and the Hospital Anxiety and Depression Scale (HADS). The General Information Questionnaire included variables related to both patients and their family caregivers, such as gender, age, marital status, educational level, monthly income, and employment status. In addition, caregiving duration was collected for caregivers, and illness-related characteristics (e.g., duration of illness) were obtained for patients.

The CBI was developed by Novak and Guest in 1989 and is a multidimensional self-assessment tool for caregiver burden (Novak & Guest, 1989). It was initially used to assess the burden on caregivers of elderly individuals with confusion or disorientation. We used our own translated version of the CBI, which encompasses 24 items. Eight of these items were derived from Novak’s review of relevant literature, while the remaining 16 items were based on interviews with caregivers. The inventory is divided into five distinct dimensions: time, development, physical, emotional, and social burden. All dimensions demonstrated acceptable internal reliability, registering Cronbach’s α values greater than .7.

Each item is rated on a 5-point response scale ranging from 0 to 4. The total burden score was normalized by taking the average of all item scores (ranging from 0 to 4), with higher scores indicating heavier perceived burden. The MSPSS was employed to measure the level of perceived social support (Zimet et al., 1988). It is a self-report questionnaire consisting of 12 declarative items designed to assess individuals’ subjective perception of the availability of social support. This instrument comprises three 4-item subscales distinguishing support obtained from family, friends, and significant others. Scoring utilizes a 7-point Likert-type response format, where the mean of all 12 items yields a final score (1–7), with greater scores indicating stronger perceived support. After obtaining authorization from the scale’s author, the existing Chinese version of the MSPSS was used for this study. The MSPSS has been demonstrated to have good reliability and validity in assessing perceived social support among family caregivers of individuals with psychiatric disorders (D. Wang et al., 2021).

The HADS, originally developed by Zigmond and Snaith in 1983 for screening anxiety and depression in general hospital settings, has gained broad acceptance due to its efficiency in assessing psychological distress across diverse clinical populations (Adejumo et al., 2021; Nikolovski et al., 2022). We utilized our in-house translated version, comprising 14 items (7 items for the Anxiety subscale, HADS-A, and 7 for the Depression subscale, HADS-D). Each item is rated on a 4-point scale (0–3). Interpretation of the total subscale scores is categorized as follows: 0–7 indicates the absence of symptoms; 8–10 suggests possible clinical symptoms; and 11–21 confirms the presence of clinical symptoms.

Statistical Analysis

Data entry quality was maintained through double entry utilizing EpiData 3.1. Subsequent data description and statistical analyses were performed using SPSS 26.0. Continuous and categorical variables were summarized using the mean (standard deviation, SD) and frequency (percentage), respectively. Cronbach’s α coefficient was calculated for each scale used in the study to test internal consistency reliability, with a value greater than .7 indicating good reliability. Differences in caregiver anxiety and depression scores based on the demographic characteristics of both patients and family caregivers were examined using independent samples t-tests and one-way analysis of variance (ANOVA). The Bonferroni correction was applied for post hoc multiple comparisons following significant ANOVA results. Pearson correlation analysis was employed to determine the relationship among caregiver burden, perceived social support, anxiety, and depression. Hierarchical regression analyses were conducted to examine the mediating role of perceived social support in the relationship between caregiver burden and anxiety and depression. For this analysis, caregiver burden, perceived social support, and anxiety/depression were mean-centered, and demographic variables of both patients and family caregivers were included as covariates in each regression step. The bootstrap method was used to formally verify the mediating effect. All statistical tests adopted a two-sided p-value of < .05 as the criterion for statistical significance.

Results

Demographic Characteristics of Patients With Schizophrenia and Family Caregivers and Univariate Analysis

A total of 393 dyads of patients with schizophrenia and their family caregivers were included in the study, and the demographic characteristics and anxiety/depression distributions are shown in Table 1.

Table 1.

Demographic Characteristics of Patients With Schizophrenia and Their Family Caregivers and Univariate Analyses of Anxiety and Depression (n = 393).

Characteristics	Patients							Caregivers
	N (%)	Anxiety			Depression			N (%)	Anxiety			Depression
	N (%)	M (SD)	t/F	p	M (SD)	t/F	p	N (%)	M (SD)	t/F	p	M (SD)	t/F	p
Sex			.98	.328		1.68	.094			.25	.802		1.13	.261
Male	181 (46.1)	4.96 (3.28)			6.54 (3.87)			192 (48.9)	4.81 (3.76)			6.40 (4.21)
Female	212 (53.9)	4.60 (3.84)			5.84 (4.36)			201 (51.1)	4.72 (3.46)			5.93 (4.10)
Age (years)			.06	.946		.29	.749			5.98	.003		13.71	<.001
≤60	284 (72.3)	4.80 (3.50)			6.26 (4.00)			90 (22.9)	3.98 (3.40)			4.78 (4.06)
61–70	63 (16.0)	4.63 (3.90)			5.86 (4.42)			156 (39.7)	4.50 (3.74)			5.74 (4.03)
>70	46 (11.7)	4.74 (3.82)			5.98 (4.70)			147 (37.4)	5.53 (3.46)			7.46 (4.02)
Marital status			1.62	.105		.44	.662			.41	.683		−1.08	.282
Married	111 (28.2)	5.23 (3.89)			6.31 (4.11)			314 (79.9)	4.80 (3.67)			6.05 (4.14)
Unmarried/other	282 (71.8)	4.58 (3.46)			6.10 (4.17)			79 (20.1)	4.62 (3.32)			6.62 (4.25)
Education Level			.66	.511		2.06	.040			1.60	.110		4.25	<.001
High school or below	299 (76.1)	4.83 (3.62)			6.40 (4.24)			318 (80.9)	4.91 (3.66)			6.58 (4.10)
University or above	94 (23.9)	4.55 (3.52)			5.39 (3.78)			75 (19.1)	4.16 (3.28)			4.35 (3.94)
Employment status			−.86	.393		−2.28	.023			−1.12	.265		−2.48	.014
Employed	36 (9.2)	4.28 (3.78)			4.67 (3.67)			56 (14.2)	4.27 (3.68)			4.89 (4.28)
Unemployed (including retired)	357 (90.8)	4.82 (3.58)			6.31 (4.17)			337 (85.8)	4.85 (3.59)			6.37 (4.11)
Monthly income (yuan)			2.66	.071		5.60	.004			13.24	<.001		19.11	<.001
≤3,000	207 (52.7)	4.79 (3.52)			6.61 (4.00)			64 (16.3)	6.25 (3.46)			8.31 (4.04)
3,001–6,000	173 (44.0)	4.91 (3.72)			5.86 (4.29)			231 (58.8)	4.92 (3.55)			6.31 (4.03)
>6,000	13 (3.3)	2.54 (2.33)			3.00 (2.83)			98 (24.9)	3.41 (3.37)			4.39 (3.77)
Duration of illness/Caregiving duration (years)			−1.04	.300		−1.72	.086			−3.63	<.001		−4.72	<.001
≤20	176 (44.8)	4.56 (3.48)			5.76 (4.12)			214 (54.5)	4.17 (3.56)			5.28 (4.11)
>20	217 (55.2)	4.94 (3.68)			6.48 (4.15)			179 (45.5)	5.48 (3.53)			7.22 (3.98)

Among the patients, 53.9% were female and 72.3% were aged 60 years or younger. Most patients were unmarried or had other marital statuses (71.8%), and 76.1% had an educational level of high school or below. The majority were unemployed or retired (90.8%), and over half (52.7%) had a monthly income of 3,000 RMB or less. In addition, 55.2% had been living with schizophrenia for more than 20 years. Among the family caregivers, 51.1% were female, and the largest age group was 61–70 years (39.7%). Most caregivers were married (79.9%), had a high school education or below (80.9%), and were unemployed or retired (85.8%). More than half reported a monthly income of 3,001 to 6,000 RMB (58.8%), and 54.5% had provided care for no more than 20 years.

The results indicated that caregiver depression varied significantly according to patient-related factors, including educational level, t(391) = 2.06, p = .040; employment status, t(391) = −2.28, p = .023; and monthly income, F(2, 390) = 5.60, p = .004. Specifically, lower educational attainment, unemployment or retirement, and lower income among patients were associated with higher levels of depression in family caregivers. Patient sex, age, marital status, and duration of illness were not significantly associated with caregiver depression (all p > .05). In addition, caregiver anxiety was not significantly associated with any patient demographic variables (all p > .05).

In addition to patient-related factors, caregiver characteristics were also significantly associated with psychological outcomes. The results indicated significant differences in caregivers’ anxiety and depression based on age, monthly income, and caregiving duration. Older caregivers reported higher levels of anxiety, F(2, 390) = 5.98, p = .003, and depression, F(2, 390) = 13.71, p < .001, compared to younger caregivers. Lower monthly income was associated with higher anxiety, F(2, 390) = 13.24, p < .001, and depression, F(2, 390) = 19.11, p < .001. Longer caregiving duration was associated with increased anxiety, t(391) = −3.63, p < .001, and depression, t(391) = −4.72, p < .001. In addition, lower educational levels and unemployment were associated with higher depression, t(391) = 4.25, p < .001, and t(391) = −2.48, p = .014, respectively, but were not significantly associated with anxiety. No significant differences in anxiety or depression were found with respect to gender or marital status (all p > .05).

Descriptive and Correlational Analysis of Caregiver Burden, Perceived Social Support, Anxiety, and Depression Among Family Caregivers of Schizophrenia Participants

The internal consistency analysis revealed that the Cronbach’s α coefficients for caregiver burden, perceived social support, anxiety, and depression were .95, .97, .85, and .84, respectively.

The mean scores and correlation coefficients of the study variables are shown in Table 2. Specifically, the mean score for caregiver burden was M = 1.08 (SD = .60), for perceived social support was M = 4.99 (SD = 1.05), for anxiety was M = 4.76 (SD = 3.60), and for depression was M = 6.16 (SD = 4.16).

Table 2.

Descriptive and Correlation Analysis of Burden, Perceived Social Support, Anxiety and Depression of Family Caregivers of Schizophrenia.

r	M ± SD	Cronbach’s α	1	2	3	4
1. Caregiver burden	1.08 ± .60	.95	1.00
2. Perceived social support	4.99 ± 1.05	.97	−.47***	1.00
3. Anxiety	4.76 ± 3.60	.85	.64***	−.40***	1.00
4. Depression	6.16 ± 4.16	.84	.57***	−.56***	.69***	1.00

***

p < .001.

Caregiver burden was significantly and positively correlated with anxiety, r(391) = .64, p < .001, and depression, r(391) = .57, p < .001, and was significantly and negatively correlated with perceived social support, r(391) = −.47, p < .001. Perceived social support was significantly negatively correlated with anxiety, r(391) = −.40, p < .001, and depression, r(391) = −.56, p < .001. Anxiety and depression were significantly and positively correlated with each other, r(391) = .69, p < .001.

Mediating Effect of Perceived Social Support Between Caregiver Burden and Anxiety/Depression

The mediational hypothesis was tested using hierarchical regression analyses. A complete presentation of these results can be found in Table 3.

Table 3.

Test on the Mediating Effect of Perceived Social Support Between Caregiver’s Burden and Anxiety and Depression (n = 393).

Project	Step	Dependent variable	Independent variable	R ²	t	β
Anxiety	Step 1	Anxiety	Caregiver burden	.448	15.37***	.614
	Step 2	Perceived social support	Caregiver burden	.245	−10.13***	−.474
	Step 3	Anxiety	Caregiver burden	.464	12.27***	.545
			Perceived social support		−3.37**	−.146
Depression	Step 1	Depression	Caregiver burden	.397	12.24***	.511
	Step 2	Perceived social support	Caregiver burden	.245	−10.13***	−.474
	Step 3	Depression	Caregiver burden	.505	7.77***	.332
			Perceived social support		−9.11***	−.379

Note. Control variables: patient-related variables (education level, employment status, monthly income, and duration of illness) and caregiver-related variables (age, monthly income, and caregiving duration). Age, duration of illness, and caregiving duration were treated as continuous variables.

p < .01. ***p < .001.

First, regression analyses were performed with anxiety and depression as dependent variables and caregiver burden as the independent variable. The results revealed that caregiver burden had a significant positive predictive effect on both anxiety, β = .614, p < .001, and depression, β = .511, p < .001. In addition, caregiver burden had a significant negative predictive effect on perceived social support, β = −.474, p < .001. When both caregiver burden and perceived social support were included as independent variables in a multiple regression analysis, it was found that caregiver burden still had a significant positive predictive effect on anxiety, β = .545, p < .001, while perceived social support had a significant negative predictive effect on anxiety, β = −.146, p < .001. This indicates that perceived social support partially mediates the relationship between caregiver burden and anxiety, with the mediation effect accounting for 11.2% of the total effect. Similarly, for depression, caregiver burden continued to show a significant positive predictive effect, β = .332, p < .001, and perceived social support had a significant negative predictive effect, β = −.379, p < .001. This suggests that perceived social support also partially mediates the relationship between caregiver burden and depression, with the mediation effect accounting for 35.0% of the total effect.

Verification of the Mediating Effect of Perceived Social Support Between Caregiver Burden and Anxiety/Depression

The findings demonstrated that caregiver burden exerted a significant direct effect on both anxiety and depression, with direct effect values of c′ = .545, 95% CI [0.458, 0.632], for anxiety and c′ = .332, 95% CI [0.248, 0.416], for depression. Perceived social support was found to be a significant partial mediator in the relationship between caregiver burden and both anxiety and depression. For anxiety, the indirect effect of perceived social support was .069, 95% CI [0.027, 0.118], whereas for depression, the indirect effect was .179, 95% CI [0.127, 0.241]. These findings indicate that perceived social support significantly mediates the association between caregiver burden and both outcomes, supporting the preliminary results obtained from the hierarchical regression approach. Detailed results are presented in Table 4 and Figure 1.

Table 4.

Verification of the Mediating Effect of Perceived Social Support Between Caregiver Burden and Anxiety and Depression.

Project	Effect	β	SE	Bootstrap, 95% CI
Anxiety	Direct effect	.545	.044	0.458, 0.632
	Indirect effect	.069	.023	0.027, 0.118
Depression	Direct effect	.332	.043	0.248, 0.416
	Indirect effect	.179	.029	0.127, 0.241

Note. Number of bootstrap samples: 5,000. Control variables: patient-related variables (education level, employment status, monthly income, and duration of illness) and caregiver-related variables (age, monthly income, and caregiving duration). Age, duration of illness, and caregiving duration were treated as continuous variables.

Figure 1.

The Mediating Role of Perceived Social Support Between Caregiver’s Burden and Anxiety and Depression.

Discussion

The findings demonstrate that caregiver burden is significantly correlated with anxiety, depression, and perceived social support. Subsequent mediation analysis established that perceived social support functions as a significant partial mediator in the association between caregiver burden and both anxiety and depression.

The mean caregiver burden score was M = 1.08 (SD = .60), indicating a moderate level of burden. This finding is consistent with previous research (Hsiao et al., 2020). The mean scores for anxiety and depression were M = 4.76 (SD = 3.60) and M = 6.16 (SD = 4.16), respectively. In comparison, family caregivers of patients with cancer reported higher anxiety (M = 6.93, SD = 4.99) and similar levels of depression (M = 5.96, SD = 4.91; Unsar et al., 2021), the caregivers in this study exhibited lower levels of anxiety but higher levels of depression. This observed difference is likely attributable to the variation in the underlying nature of the diseases and the resultant heterogeneity in caregiver burden. One possible explanation is that when schizophrenia remains relatively stable with fewer relapses, caregivers may face fewer acute disruptions in daily care, which could help reduce anxiety to some extent (Tristiana et al., 2019). However, factors like prolonged caregiving demands, psychological strain from patients’ abnormal behaviors, and social discrimination may contribute to higher depression levels (Prasad et al., 2024).

This study indicated that as the age of family caregivers increases, levels of anxiety and depression tend to worsen. In this study, the majority of family caregivers were already older adults. With increasing age, caregivers experience a gradual decline in physical functioning and reduced adaptability to their environment (Rahmani et al., 2022; Schulz et al., 2016). Moreover, long-term caregiving depletes their energy and financial resources, making it difficult for them to effectively handle daily caregiving tasks, which can lead to various psychological issues. Educational level also plays a role in caregivers’ depressive symptoms. Caregivers with lower education levels may lack the knowledge and skills needed to cope with stress and seek help, leading to greater feelings of helplessness and despair (Zhou et al., 2021). In addition, the current employment status affects caregivers’ mental health. Full-time caregivers often experience higher psychological stress and more severe depression due to a lack of social interaction and reduced job satisfaction. Conversely, caregivers who can continue working, despite facing dual pressures of work and caregiving, may receive psychological support and relief from work, which can reduce their mental stress and depression to some extent (Gater et al., 2014). In addition to caregiver-related factors, patient characteristics were also associated with caregiver depression. Specifically, lower educational attainment, unemployment or retirement, and lower income among patients were linked to higher levels of depression in caregivers. Patients with lower education may have limited illness insight and poorer self-management, thereby increasing caregiving demands (Lysaker et al., 2018). Moreover, the illness itself can impair patients’ social and occupational functioning, leading to unemployment and reduced income, which further increases financial strain on the family (Bouwmans et al., 2015). Under the combined effects of caregiving and economic burden over time, caregivers may be more likely to experience depressive symptoms.

The study found that caregiver burden is positively correlated with anxiety and depression. This finding suggests that caregivers facing a greater burden exhibit an increased propensity to experience anxiety and depression, which is consistent with previous research (Del-Pino-Casado et al., 2021; Riley-McHugh et al., 2016). Caregivers with higher burdens often face greater levels of stress and emotional exhaustion, leading to reduced psychological resilience and difficulties in managing daily challenges. The demands of caregiving also consume their self-care time, further increasing the risk of anxiety and depression. In addition, caregiver burden is negatively correlated with perceived social support, suggesting that higher levels of perceived social support may be linked to lower levels of burden among family caregivers. This finding is consistent with previous studies (Hegde et al., 2019; Jagannathan et al., 2014). Furthermore, higher perceived social support has been associated with lower psychological distress, including symptoms of anxiety and depression. A cross-sectional study reported that caregivers who perceived moderate to high levels of social support had a lower risk of developing depression, anxiety, and stress compared to those with lower levels of perceived social support (Binti Sharkawi et al., 2020). A systematic review and meta-analysis showed that perceived social support was negatively associated with caregiver anxiety, while received social support demonstrated a weaker association, suggesting that subjective perceptions of support may be more important for psychological well-being than objective support (Priego-Cubero et al., 2023).

The mediating effect of perceived social support in the relationship between caregiver burden and anxiety and depression was further validated through hierarchical regression analysis. Higher caregiver burden is commonly associated with increased role strain and emotional exhaustion, which may elevate the risk of anxiety and depressive symptoms (Karambelas et al., 2022). In contrast, greater perceived social support may strengthen caregivers’ sense of being understood, supported, and respected, thereby reducing the perceived threat of caregiving stress and alleviating psychological distress (Lok & Bademli, 2021; Raj et al., 2016). Given that perceived social support reflects caregivers’ satisfaction with support from family, friends, and significant others, its protective role may also operate through attenuating the internalization of public stigma (Zimet et al., 1988). Internalized stigma, defined as the perception and endorsement of public stigma and societal prejudice, may be diminished when caregivers experience sufficient understanding and support from others, which in turn may contribute to lower caregiver burden and emotional distress (Ociskova et al., 2015). This finding suggests that strengthening caregivers’ perceived social support through multi-level and accessible support systems may be an effective strategy to reduce psychological burden and improve mental health outcomes among caregivers.

However, this study is subject to several limitations. First, the sample was restricted to one region in China, which may compromise the generalizability of the findings. Second, the study design was cross-sectional, precluding the establishment of causality between variables. Finally, information regarding patients’ medication use and comorbid conditions was not collected, which might affect the psychological state of caregivers. Future research should consider expanding the sample range, using longitudinal designs, and incorporating objective assessment indicators for more comprehensive results.

In summary, caregiver burden is positively associated with anxiety and depression among family caregivers of patients with schizophrenia, while perceived social support is negatively associated with these outcomes and partially mediates these relationships. These findings highlight the important role of perceived social support in caregivers’ psychological well-being and contribute to an understanding of the underlying mechanisms in this field. Future longitudinal and interventional studies are needed to further clarify these associations and inform targeted support strategies for family caregivers.

Footnotes

ORCID iD

Jiwei Wang

Author Contributions

Yuxin Hao: Data curation, Formal analysis, Writing – original draft, Software, Methodology, Investigation.

Qiongting Zhang: Writing – original draft, Resources, Data curation, Conceptualization.

Tantan Cheng: Writing – original draft, Resources, Data curation.

Bingqi Han: Writing – review & editing, Data curation, Validation, Conceptualization.

Shuruo Zhang: Writing – review & editing, Conceptualization.

Wei Jin: Writing – review & editing, Writing –original draft, Conceptualization, Supervision.

Jiwei Wang: Writing – review & editing, Writing – original draft, Conceptualization, Supervision.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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