Stress Sub-Categories and Suicidal Ideation Encountered by Family Carers of Patients with Traumatic Brain Injury

Keywords

Stress sub-categories; Suicidal ideation; Traumatic brain injury; Family carers

Abstract

Background: This study’s aim was to ascertain differential effects of specific stress-related sub-categories of the total stress response in family members who care for patients with TBI at home, to what extent they are associated with suicidal ideation respectively and their practical implications.

Materials and methods: The study sample was comprised of randomly selected volunteer family members (N = 80) caring at home for a relative with TBI. Individually administered standardized measures were used, viz., the Stress Symptom Checklist (SSCL) with three separate sub-categories of stress responses: physical symptoms, psychological symptoms and behavioural symptoms and question 9 (Q9) of the Beck Depression Inventory (BDI).

Results : The total stress scores of the sample (including all three sub-categories) were elevated and varied, reflecting their non-normal distribution. However, differences in most scores were higher on the behavioural one associated with suicidal ideation than the physical and psychological sub-categories. The study confirmed that an interaction of stress-related sub-categories affect moderating variables differently in family members who care for TBI patients at home.

Conclusion : Early detection and treatment of the onset of the different sub-category symptoms brought on by chronic stress, in particular the often misunderstood behavioural stress-related reactions/symptoms (including possible suicidal ideation) in family carers of TBI patients, can contribute to improving long-term quality of life for both the family caregivers and the patients with TBI they care for

Citation

Schlebusch L, Walker J. (2024) Stress Sub-Categories and Sui cidal Ideation Encountered by Family Carers of Patients with Traumatic Brain Injury. SM J Trauma Care 5: 6.

INTRODUCTION

Although the incidence differs between ages, study sites and countries worldwide, Traumatic Brain Injury (TBI) is a serious public health concern [1-10] with some referring to it as a silent epidemic [2] or hidden pandemic [8]. Causes vary, but prominent are the high number of road traffic accidents globally [2], in subSaharan Africa [1] and in South Africa [4-6]. An increasing number of patients survive TBI because of progress in modern healthcare while, for several reasons, including resource limitations in some instances, a growing population of patients living with the long-term effects of TBI, are being cared for by family members at home who have to help them reintegrate into family and community environments and with psychological adaptation [8,9,11,12].

TBI can result in longstanding and diverse sequelae, including psychological/psychiatric complications, neuropsychological/cognitive deficits, changes in behaviour/personality and executive functioning, as well as in social, financial, physical and secondary medical ones and the psychological effects of managing and coping with these in patients can cause excessive caregiver burden in families who care for them [9,12-20].

Such experiences can exacerbate challenges in various life domains for family caregivers, which could induce profoundly elevated stress in them, thereby negatively affecting their coping skills that in some carers can be severe enough to lead to suicidal ideation [19]. The human stress response has been shown to follow two pathways, i.e. a physiological and psychological one and both chronic and acute stress can be critical co-morbid variables in reduced coping with untreated, unhealthy stress leading to detrimental physical, psychological and/or behavioural symptoms [21-31]. This, in turn, can increase existing caregiver burden associated with reduced psychological resilience in family members caring for patients with TBI [20]. However, despite the above there is comparatively limited research on stress in family members who care for patients with TBI at home in low and middle income groups, particularly in South Africa [12,18,19] and notably in respect of the different sub categories of such stress and its implications for suicidal ideation as explicated in the materials and methods section below.

MATERIALS AND METHODS

Aim

As part of an extended research project [12,19,20,32], this study’s aim was to ascertain differential effects of specific stress-related sub categories of the total stress response in family members who care for patients with TBI at home. That is, whether they experienced primarily physical, psychological or behavioural reactions and/or symptoms of stress, to what extent they are associated with suicidal ideation respectively and to provide a synthesis of the key research findings and their practical implications.

Sample and Study design

The study sample was comprised of randomly selected volunteer family members (N = 80) caring at home for a relative with TBI and who attended support groups at Headway Gauteng (a brain injury association which is a registered non-profit organisation dedicated to offering various support programmes to adult survivors of TBI, their family members and caregivers), Hyde Park and Soweto branches, Johannesburg, South Africa. Participants ranged between the ages of 18 and 75, were English literate with various educational levels, were able to understand the study and give written informed consent on the appropriate form, prior to being included in the study.

The research incorporated a mixed methodology that involved a cross-sectional descriptive and phenomenological approach. From a theoretical perspective it was based on an integrated biopsychosocial model [24,25,28,33] underpinned by aspects of general systems theory [34], the fact that human health should be holistically perceived in terms of biological, psychological and social factors, along with the stress-diathesis and stress-vulnerability models of stress and health [28,33,35-38]. We also wanted to highlight consideration that different subcategories of prolonged stress can have different detrimental effects in individuals with specific vulnerabilities.

Individually administered standardized measures were used, viz., the Stress Symptom Checklist (SSCL) [24,25] and question 9 (Q9) of the Beck Depression Inventory (BDI) [39]. The SSCL is a reliable, valid and clinically useful dichotomous-scaled 87-item checklist of the general signs and symptoms of unhealthy stress, with three separate sub-categories of stress responses: physical symptoms (18 items); psychological symptoms (27 items); and behavioural symptoms (42 items). The highest total score is 87, with scoring categories being: low stress = 8 and below; mild stress = 9 to 15; moderate stress = 16 to 30; severe stress = 31 to 45; and profound stress = 46 and above. Stress reactions are measured by how often they occur. Scores higher than three on any of the subcategories indicate symptoms of unhealthy stress for that sub-category. The SSCL has been extensively used in adults in divergent research populations [32,40 46]. Q9 of the BDI has a choice of one of four options: 0 = I don’t have any thoughts of killing myself; 1 = I have thoughts of killing myself, but I would not carry them out; 2 = I would like to kill myself, or 3 = I would kill myself if I had the chance. For the purpose of this study, a score of 1 to 3 denoted suicidal ideation. Scores obtained on the SSCL sub-categories were compared with those obtained on Q9 of the BDI. These scores were non-normally distributed, therefore nonparametric statistical tests were used (including the Kruskal-Wallis, Mann Whitney and Chi-Square Tests with a significance level of P = 0.05).

Results

As per our earlier findings [19], the total SSCL stress scores of the sample (including all three sub-categories) varied, reflecting their non normal distribution that ranged from low (8.8%), mild (13.8%), moderate (31.3%), severe (17.5%) to profound (28.7%). The majority (77.5%) of family carers of TBI patients suffered from deleterious stress levels and with regard to sub-category differences, the psychological sub-category scores were more elevated than the physical ones. However, although their scores were still very high, most scored lower on the physical and psychological sub-categories compared to the higher behavioural one (Figure 1), which tends to suggest the significance of the behavioural stress-related impact on the carers while potentially downplaying the effects of the other sub-categories [12,19].

Figure 1: Stress-related behavioural sub-category

Graphic representations of the severity of the sub-category stress symptoms are represented in the boxplots (Figures 2-4), portraying their linear trend with Q9 of the BDI and a positive association between the sub-scores, but with increasing differences in stress levels with most scores being higher on the behavioural one associated with suicidal ideation than the physical and psychological sub-categories of the SSCL.

Figure 2: Stress-related physical sub-category.

Figure 3: Stress-related psychological sub-category.

Figure 4: Stress-related behavioural sub-category.

DISCUSSION

Given the study outcome, there is a noteworthy probability that, in addition to overall elevated stress levels experienced by family members who care for patients with TBI, if the behavioural stress-related symptoms are not identified and adequately managed they could lead to suicidal ideation in some family carers and form part of a neglected cause of pathological stress. There can be a lack of awareness of the behavioural changes in patients with TBI such as aggression and disinhibition that have been reported by family members as some of the most difficult to cope with [47,48]. This has also the propensity to effectuate stress related behavioural reactions in their family caregivers. A tendency towards a high percentage of behavioural stress-related as opposed to physical and psychological symptoms has been noted before, an example being suicidal behaviour [19].

A connection between stress, depression and suicidal ideation can adversely affect the psychological coping of family members who care for patients with TBI at home [19,20], especially if they do not feel adequately prepared by healthcare professionals to deal with the neuropsychological and behavioural aspects of TBI resulting in family conflict once the patient started being cared for at home. Globally and in South Africa suicidal behaviours are high, but there are not always accurate statistics recorded due to several reasons including, inadequate data collection, personal, cultural, religious and other reservations [49-61]. Likewise, psychiatric disorders, psychological distress and their potential suicide risk patients with TBI encounter have been well-examined, as have depression and feelings of hopelessness experienced by caregivers of patients with TBI [9,12,19,26,57,60,62-71].

Behavioural difficulties can result from damage to frontal executive functioning and reduced self-awareness in TBI patients [9,48]. In general, behaviour can be understood in terms of cognition (the information processing aspect), emotionality (involving feelings and motivation) and executive functioning (involving the expression of behaviour) and although interrelated, the cognitive functioning has tended to receive more attention especially in neuropsychological assessment) [9]. In respect of our present research findings, behavioural symptoms can also increase through the stress experienced by family caregivers of TBI patients. Furthermore, such chronic stress can undermine the physiological process of allostasis, effecting an allostatic overload and adversely impact on the individual’s health and well-being [23,72,73], which appear to contribute to the high percentage of medical diagnoses reported by family members after they became caregivers to patients with TBI [12]. There is often a misunderstanding by the family members and others of TBI and its effects on the patients’ functioning [2,3,9,20]. Since the same applies to the behavioural stress-related effects on the family caregivers, it points to the necessary need of helping carer family members not only to cultivate more effective coping mechanisms to alleviate their overall caregiver burden [9,20,74,75], but how to identify and address the symptoms of different stress-related sub-categories as highlighted by us before [19], and especially the behavioural expressions thereof which can be mired in the complexities of their unmet needs. In this regard the importance of the role of healthcare professionals who treat patients with TBI and their family members can hardly be overstated in terms of educating and preparing the family caregivers and to consider referring them to appropriate sources for relevant support and professional treatment where necessary [20]. Comprehensive maximized and flexible long-term support [18-20] through facilitating improved coping also requires carer family members’ to seek assistance from other family members, support groups, exploring what combination of strategies work for them and to strive not only to understand the behaviour changes in the patient with TBI, but also their own and any underlying potential for suicidal ideation.

In conclusion, the results of the present study confirmed that an interaction of stress-related sub-categories affect moderating variables differently in family members who care for TBI patients at home. Important aspects of their stress management to enhance their ability to cope with the challenges they face are the provision of stresssymptom screening, education, ongoing support and referral by healthcare professionals for appropriate intervention according to individual personal circumstances when required. Early detection and treatment of the onset of the different sub-category symptoms brought on by chronic stress, in particular the often misunderstood behavioural stress-related reactions/symptoms (including possible suicidal ideation) in family carers of TBI patients, can contribute to improving long-term quality of life for both the family caregivers and the patients with TBI they care for.

ACKNOWLEDGMENT

The authors would like to express their grateful thanks to Headway Gauteng, Johannesburg, South Africa (the brain injury association), the staff at Headway and to all the research participants. Appreciation is also extended to Adikha Mungaroo and Prenisha Pillay for administrative support and to Tonya Esterhuizen for her biostatistical assistance. 

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Citation

Schlebusch L, Walker J. (2024) Stress Sub-Categories and Suicidal Ideation Encountered by Family Carers of Patients with Traumatic Brain Injury. SM J Trauma Care 5: 6.