The impact of caring for family members with mental illnesses on the caregiver: a scoping review

Summary A large number of multidisciplinary, qualitative and quantitative research suggests that providing care for family members with mental health illnesses can have both positive and negative effects on the carers’ wellbeing. However, to date a comprehensive overview and synthesis of literature that compares and contrasts positive and negative effects of family-caregiving on the carer is missing. To address this gap, this scoping review examines the effects of family-caregiving on carers’ wellbeing. A Boolean search generated a total of 92 relevant articles that were included in the analysis. The results suggest that, to understand the effects of family-caregiving on the carer’s mental and physical wellbeing, it is necessary to take a combination of situational and sociodemographic characteristics into consideration. Elderly, female, spousal-carers and primary-carers may be a group that is at risk of suffering from a lack of positive mental and physical wellbeing as a result of caring. However, the negative effects of caregiving can be balanced by extraversion, social support and religious or spiritual beliefs. Therefore, future interventions that aim to promote family caregivers’ wellbeing may need to take personality, particular circumstances as well as cultural and personal beliefs into consideration.


INTRODUCTION
According to recent studies, an increasing number of people experience mental health disorders (Fernando, 2014;Bruffaerts et al., 2015;Polanczyk et al., 2015;Hanna et al., 2018).Due to a global deinstitutionalization of the treatment of mental illnesses, only a low proportion of those suffering from mental illnesses are admitted to hospitals (WHO, 2017).Of those who are hospitalized, 30-50% experience a relapse of symptoms within the first 6 months and 50-70% in the first 5 years after being discharged (Chang and Chou, 2015;Ali et al., 2017;Sadock et al., 2017).Comorbidity with other mental illness, non-adherence to medication, shorter duration on treatment and experiencing stressful life events as well as high disability score, and a single admission history are significant predictors of mental health relapse (Agenagnew and Kassaw, 2020;Moges et al., 2021).Patients with psychotic disorders who also experience common mental health disorders such as depression and anxiety are more likely to experience a relapse (Ali et al., 2017;Moges et al., 2021).Some novel approaches such as receiving low-intensity personalized advice via text-messages posttreatment (Malins et al., 2020) and specific forms of therapy such as Acceptance and Commitment Therapy (Østergaard, 2020), mind-body relaxation and therapies that allow the patient to develop healthy coping skills (Melemis, 2015) can be particularly beneficial in relapse prevention.However, as family and spousal carers live with patients and are usually the first to recognize behavioural changes, they play an increasingly important role in supporting and rehabilitating those who suffer from mental health illnesses.
The challenges that family members who care for those with mental health illnesses face are well documented in the literature.Family caregivers are at an increased risk of suffering physically, psychologically and socially while providing care for family members with mental health conditions (Sharma et al., 2016;Akbari et al., 2018;Norris et al., 2018;O ¨zgo ¨nu ¨l and Bademli, 2022).Specifically, studies have shown that caring for family members with mental health problems can lead to social isolation, financial difficulties, occupational restrictions and negative emotions such as anger, aggression, frustration, low self-esteem, constant worry and feelings of helplessness (van der Sanden et al., 2013(van der Sanden et al., , 2015;;Yin et al., 2014;Lamont and Dickens, 2021).In addition, there is an increased risk of reduced lifeexpectancy, lower wellbeing and mastery of life skills, and less time spent doing leisure activities for family caregivers (Akbari et al., 2018;Hsiao et al., 2020;McKee, 2020;Dadalto and Cavalcante, 2021).
Yet, research also shows that caring for a family member may also affect the caregivers in positive ways (Roth et al., 2015).For example, literature suggests that some family carers can become more resilient over time (Crellin et al., 2014;Donnellan et al., 2015;Ong et al., 2018;Post et al., 2021).While there are different definitions for caregiver resilience in the literature, they all share similar descriptions for the characteristics for overcoming adversity.This is explained as not only being about surviving the burden associated with caring for a mentally ill family member, but also growing into a stronger, more adaptable and healthier person (Amagai et al., 2016;Pione et al., 2021).In addition, family caregiving can improve the relationship between the caregiver and the person they care for, while also providing a sense of inner strength and satisfaction (Kate et al., 2013;Roth et al., 2015;Grover et al., 2017;Shiraishi and Reilly, 2019).
While previous research examined possible challenges and advantages of caring for family members with mental health problems, a comprehensive overview and synthesis of the literature appears to be missing.This is problematic, as there is a need to understand the unique challenges that family carers face and determine possible sources of help and support that would allow for implementation of informed strategies to meet the carers' needs.The present study addresses this gap by reviewing empirical studies and scientific evidence to capture both the challenges and positive aspects of caregiving in the family context.

METHODS
A scoping review was used to synthesize the relevant literature on family caregiving (Arksey and O'Malley, 2005;Levac et al., 2010).Scoping reviews are a 'useful way of mapping fields of study where it is difficult to visualize the range of material that might be available' [ (Arksey and O'Malley, 2005), p. 21].They allow for a synthesis of the literature across different academic disciplines.This technique was relevant to the present study as empirical inquiry surrounding positive and negative effects of family caregiving are the subject of interest in various disciplines.For example, clinical studies might examine the physical and mental health effects of family caregiving, and psychological studies observe the severity of caregiver burden or changes in identity formation, whereas sociological studies tend to focus on the effects of family caregiving on social structures such as families or friendship networks.A scoping review utilizes a rigorous methodological framework consisting of five steps, which includes contributions from several disciplines.It maps the terrain of existing research and highlights gaps in knowledge (Arksey and O'Malley, 2005;Levac et al., 2010).As a method for reviewing literature, scoping studies have distinct characteristics (Arksey and O'Malley, 2005).Unlike systematic reviews, they address broader topics and topic areas in which many different study designs might be applicable (Arksey and O'Malley, 2005).Therefore, this approach was suitable to identify relevant themes in family caregiving in relation to caregiver health and wellbeing.The present study utilized Arksey and O'Malley's (Arksey and O'Malley, 2005) five-step protocol of scoping reviews because this is one of the most frequently utilized and published frameworks in scoping review literature (i.e.Abraham et al., 2010;Halas et al Walsh et al., 2019).The five steps include: (i) identifying the research question, (ii) identifying relevant studies, (iii) study selection, (iv) charting the data and (v) collating, summarizing and reporting the results.Each step is outlined in more detail below.
Step 1: Identifying the research question The first methodological step when conducting a scoping review is to determine the focus of the research question (Arksey and O'Malley, 2005;Levac et al., 2010).A research team from Robert Gordon University (Aberdeen), Anglia Ruskin University and the Forces in Mind Research Centre (Chelmsford) considered the appropriate balance of breadth and depth for the research topics (Arksey and O'Malley, 2005;Levac et al., 2010) during the literature review.The following questions were determined in December 2020 and guided the scoping review: "How does family caregiving affect the caregiver physically, mentally and socially?"and "How can family carers be best supported?".
Step 2: Identifying relevant studies Guidelines concerning the identification of the literature in scoping reviews, include the development of search terms, identification of databases, and the establishment of time frames, were followed (Levac et al., 2010).Therefore, the present review drew on a broad interpretation of search strings related to family caring and wellbeing.Step 3: Study selection Decisions surrounding the inclusion and exclusion of studies in a scoping review rely upon an iterative and collaborative process involving all members of the researcher team (Levac et al., 2010).To address this we used the Preferred Reporting Items for Systematic Reviews flow diagram (cf. Figure 1; Moher et al., 2009).
Databases were searched with a combination of search strings and Boolean operators to ensure the inclusion of at least one search string from the terms listed in Table 1.Both qualitative and quantitative studies were included.The exclusion criteria were the publication being an editorial or review article, studies with a primary focus on the care receiver and not the family carer, the patient being a child or adolescent (under 18 years of age) and studies about caring for physical health disorders.Editorial and review articles were examined to ensure the complete retrieval of relevant primary research noted therein.
Step 4: Charting the data In scoping reviews, charting the data involves reviewing, documenting and sorting the information that was retrieved in accordance with the key issues and themes (Arksey and O'Malley, 2005).An Excel spreadsheet was used to extract, document and organize the relevant information from each reviewed article (Levac et al., 2010).The spreadsheet included separate columns for article title, authors, database from which the article was drawn, the population and social-cultural background, mental illness of the patient whom family carers supported, methodological framework, instruments used in the study, method of analysis, main findings, implications and any additional information (e.g.screenshots of tables and figures).
Step 5: Collating, summarizing and reporting the results The articles were read independently by members of the research team and topics relevant to the purpose of the review were identified.The research team compared, summarized and collated the identified preliminary themes.The data were then re-examined and reorganized to reflect deeper and more nuanced perspectives of the studies' findings.Based on common meanings and central issues, the findings for each study were organized and integrated into categories and themes to highlight prevalent issues and gaps in knowledge.The research team commenced with collating, summarizing and reporting the results in April 2021 and concluded this step in August 2021.

RESULTS
Boolean searches including the string search terms generated a total output of 736 articles.From these 736 articles, 83 were excluded as they were duplicates.The research team examined the remaining 653 articles for inclusion/exclusion independently.Concordance in interrater reliability was high with the researcher team agreeing on inclusion and exclusion of 646 of the 653 articles (98.93%).Arguments for inclusion or exclusion of the remaining seven articles (1.07%) were discussed and consensus on inclusion/exclusion was reached before commencing with further analyses.The initial screening involved reading the abstracts and skimming the tests, which identified 281 articles that could potentially qualify for inclusion in the review.These 281 articles were read in detail.From the 231 articles, a total of 189 were excluded from further review, based on the exclusion criteria (cf.Table 1).Therefore, a total of 92 studies were included in the present review, of which 14 were qualitative and 78 were quantitative studies.Most studies focussed on American or British participants.Other countries represented were Australia, Canada, Chile, China, Colombia, Cyprus, Finland, Germany,

Negative implications of caring for family members with mental health diseases
A major theme was the negative impact on the family caregiver's physical and mental health.Most of the articles included in this review examined clinical levels of psychological distress in family carers (33.7%; 31 studies) and depression and depressive symptoms in relation to family caregiving (21.17%, 20 studies).This indicates that providing primary care for family members can have problematic consequences on the carers' wellbeing.For example, Mausbach et al. (Mausbach et al., 2014) conducted a longitudinal study comparing the individual experiences of 126 spousal carers for Alzheimer patients.The placement of the care receiver into care homes was associated with significant reductions in depressive symptoms, activity restriction and an increase in personal mastery in caregivers.These results are supported by studies that examined levels of psychological distress and depressive symptoms in primary and secondary caregivers across different mental health diseases and different cultures [i.e.(Colvez et al., 2002;Gonc¸alves-Pereira et al., 2020;Zwar et al., 2020)].
However, while primary care for family members can have negative consequences on carer wellbeing, sociodemographic factors can also determine the extent to which individuals may be affected by such negative consequences.For example, 32 (34.78%) of the reviewed studies indicated that gender significantly impacts on the care givers self-perceived burden of care.The results from these studies are consistent in suggesting that female family caregivers experience higher levels of psychological distress, shame and caregiver burden [i.e.(Pattanayak et al., 2010;Chiang et al., 2015;Gresswell et al., 2018;Avdikou et al., 2019;Brites et al., 2020)].This trend was evident across different cultures and applied to various mental health disorders equally (Papastavrou et al., 2009;Nordtug and Holen, 2011;Po ¨ysti et al., 2012).In addition, if wives cared for their husbands, they experienced lower marital satisfaction, while the opposite effect was observed in husbands caring for their wives (Beeson, 2003;Dahlberg et al., 2007;Lai, 2012;Choi, 2018).The literature around this phenomenon suggests that women feel more responsible for providing care and as a result are left with multiple competing roles (Calasanti and Bowen, 2006;Dahlberg et al., 2007).Women are therefore more likely to experience a loss of self and loneliness when caring for a family member making them more susceptible to caregiver depression, whereas men are more comfortable with letting others assume the carer role, and are more selfreliant on themselves and others to provide social support (Calasanti and Bowen, 2006;Brown and Chen, 2008;Sun et al., 2008;Ruisoto et al., 2020).
The role of the carer and their relationship with the care-receiver was also found to impact on individual wellbeing.Specifically, research suggests that close ties such as being a spouse and/or living together with a mentally ill person in an acute setting determines the caregiver's experiences of burden of care.For example, in their quantitative study with 455 close relatives, found that burden was particularly high among spouses, as they feel more isolated and have less leisure time than other family carers.In addition, findings suggest that spouses who care for partners with mental health disorders are exposed to additional stressors that originate from an internal conflict of roles were they are perceived to 'hold it all together' in their relationship [ (Casarez et al., 2019), p. 393].In this sense, spouses need to handle challenging behaviours such as reckless spending or rageful and hypercritical behaviour, minimizing any issues that might arise during social encounters (Casarez et al., 2019).Besides the emotional burden, spousal carers may also experience financial difficulties as they often give up their work to care for their loved ones.
The impact of caring for family members with mental illnesses Greenwood, N., Pound, C., Brearley, S. and Smith, R. (2019).A qualitative study of older informal carers' experiences and perceptions of their caring role.The impact of caring for family members with mental illnesses • 108 informal carers; Spousal relationship was most • Common (61%), as was carer co-residence with the person with dementia (78%).
• 37 carers partners (n ¼ 15/37), parents  The impact of caring for family members with mental illnesses  The impact of caring for family members with mental illnesses  The impact of caring for family members with mental illnesses This poses additional problems as financial uncertainty contributes to clinically significant levels of distress, caregiver burden and depression among family carers (Lai, 2012;Abu Bakar et al., 2014;Temple and Dow, 2018;Wayland et al., 2021).Therefore, spouses may be at risk of compromising their own wellbeing when delivering primary care, due to greater emotional and financial strain.
Another key determinant in the prediction of family carer's wellbeing is age.Studies in this review suggest that challenging experiences in relation to family caring were perceived to be more difficult or worse for older carers (Chiang et al., 2015;Chow andHo, 2015: Tsai et al., 2021).Essentially, elderly family carers may not understand mental health issues or have the stamina required to overcome the challenges of caring, for example accessing formal support (Chiang et al., 2015;Greenwood et al., 2019).In addition, their own health conditions can compromise the ability to perform physical tasks, and thus diminish their social circle.Potential sources of social support can also decrease with age, while their own health conditions can make it harder to leave their home, and engage in leisure activities or make new friends.

Positive implications of caring for family members with mental health diseases
While most literature examines the negative psychological and physical consequences of caregiving on the carer, there is an increasing emphasis on the positives that bring balance to this point of view.A total of 16 studies (17.39%) in this review investigated the full range of caregiving experiences, including potential positive aspects and benefits of caregiving.Essentially, caregiving can be a rewarding experience that facilitates personal growth, maturity and resilience (Netto et al., 2009;Sa ´nchez-Izquierdo et al., 2015;Quinn et al., 2015) with population-based surveys indicating that caregiving may relate to significantly reduced all-cause mortality rates in comparison to a matched sample of non-caregivers (Brown et al., 2009;O'Reilly et al., 2008).Caregivers often report feeling gratitude and a sense of mastery, meaningfulness and coherence in their existence (Cohen et al., 2002;Quinn et al., 2012;Cheng et al., 2017).Therefore, the findings that suggest positive aspects of caregiving to be inversely related to burden and depression are unsurprising [i.e.(Hilgeman et al., 2007)].
Theoretical models offer different explanations to understand these positive changes in the caregiver's life.For example, the adaption stress and coping model (Folkman, 1997), suggests that positive psychological states are associated with finding positive meaning in adversity, and helping the individual to make sense of the situation.This can result in the caregiver identifying positive changes in their life (Park, 2010).Fredrickson et al. (Fredrickson et al., 2003) take a similar approach in their broaden-and-build theory by suggesting that positive emotions contribute to cognitive broadening, which then widens the individual's attention, thinking and behaviour.This broadening effect helps foster a range of adaptive and durable personal resources that contribute to the development of resilience (Fredrickson, 2004).Similarly, theories that are based on benefitfinding imply that adaptive coping emerges over time as a way of responding to stressful circumstances.This enables personal growth and fosters resilience.
In addition to situational and personal factors, literature indicates that adaptive coping also depends upon demographic characteristics.For example, caregiver personality characteristics such as extraversion and agreeableness along with social support (especially support from loved ones) are associated with positive aspects of caregiving (Koerner et al., 2009).Ethnicity can also impact on the experience of positive aspects in caregiving.Studies show that African Americans report more positive caregiving outcomes associated with active coping styles and greater resilience in comparison to Caucasians (Dilworth-Anderson et al., 2005;McCallum et al., 2006;Merritt et al., 2011).This is consistent with studies in which African American family caregivers were less affected by depression, caregiver burden and strain than white family caregivers (Haley et al., 2004).A study by Roth et al. (2015) also found that African American family carers felt more capable at appreciating and developing a positive attitude towards life when compared to Caucasians.This positive attitude towards care is explained as a reflection of long-standing traditions of the African American community.This attitude is cultivated in early life through racial socialization and maintained in adulthood life through spiritual and  (2004) outlined similar findings but added that religiosity partially mediates the relationship between ethnicity and the elevated positive attitudes in caregiving among African Americans.Although symptoms of depression were not associated with baseline levels of positive aspects in caregiving, Roff et al. (Roff et al., 2004) found that lower anxiety levels, less worrying and lower socioeconomic status among African American caregivers contributed to higher levels of positive aspects in caregiving.In conclusion, positive aspects of caregiving may be related to coping and having a more optimistic outlook on life.
Moderating factors that can contribute to the family carers' wellbeing A total of 44 studies (47.82%) suggest that tailored means of support are pivotal in improving family carers' physical and mental wellbeing.Here, a particular focus is placed on examining the individual needs of the family caregiver and how these may be addressed (Temple and Dow, 2018).Findings from the review suggest that the most prevalent types of unmet needs include financial, physical and social support [i.e.(Highet et al., 2005;Temple and Dow, 2018;Brickell et al., 2019;Casarez et al., 2019;Jones et al., 2019;Alasmee and Hasan, 2020;Anchan and Janardhana, 2020;Brites et al., 2020;Lai et al., 2020;Teles et al., 2021)].Temple and Dow's (2018) findings indicate that having any unmet needs for support increased the likelihood of the carer experiencing psychological distress two-fold.With each successive unmet need for support, the odds of psychological distress increased another 1.37 times.Therefore, besides the previously discussed negative effect of financial burden (7 studies; 7.61%), maintaining social connections (17 studies; 18.48%) and receiving professional or social support (16 studies; 17.39%), unmet needs are key factors in understanding and addressing the carer's physical and psychological wellbeing.
Increasing social resources was found to reduce the risk of suffering from poor mental health in family caregivers for patients with different mental illnesses (Gaugler et al., 2004;Griffin et al., 2017;Otero et al., 2019).This may be explained by feelings of social connectedness counteracting the effects of loneliness and social isolation that are associated with depression and depressive symptoms in family carers (Beeson, 2003;Vasileiou et al., 2017;McAuliffe et al., 2018).In this sense, empathy and social connections with family and friends as well as healthcare staff can provide a source of strength and a sense of mastery in one's predicament (Shanley et al., 2011).Peer support groups may be particularly relevant in reducing the burden of care by providing the family carer with a feeling of social connectedness with individuals who share similar experiences (Shanley et al., 2011).In addition, peer support groups give family carers the space and opportunity to reflect on their own caring routine, helping them cope more effectively with the competing demands of care (Stanley et al., 2017).
In addition to peer support groups, research suggests that smartphone technologies (i.e.applications) can help improve and maintain family carers' physical and mental health.For example, Casarez et al. (Casarez et al., 2019) report that using mental health (mHealth) apps leads to a reduction of carer burden and distress and an increase in social contacts.They not only improve the relationship between carer and care-receiver but help them to manage the administration of medication and contribute to mental health literacy.Specifically, mHealth apps can provide information for family carers on how to manage symptoms of mental health disorders, what to do in difficult situations, provide constructive practices and alert users to the need for professional interventions.This is important because information about mental health symptoms can foster an understanding of the care receivers' experiences and reduce burden and distress in caregivers [i.e.(Vasileiou et al., 2017;Brickell et al., 2019;Casarez et al., 2019;Jones et al., 2019;Alasmee and Hasan, 2020;Anchan and Janardhana, 2020;Hahn et al., 2020;Lai et al., 2020;McGaw et al., 2020;Wayland et al., 2021)].However, while mental health literacy is crucial in improving caregiver wellbeing, studies have found that in certain situations, carers are not interested in information about the mental health illness of the care receiver (Williams et al., 2014).Rather, Williams et al. (Williams et al., 2014) suggests that caregivers adopt active informationseeking techniques to not only deal with current problems and to increase their sense of control, but avoid considering future logistics of caregiving when they feel helpless or overwhelmed with stress.Thus, caregiving stressors affect the extent to which caregivers may adequately utilize the information and service provisions available.In conclusion, for them to be effective, resources must be tailored to the caregivers' individual needs.
Importantly, cultural differences need to be taken into consideration when tailoring support [i.e.(Sun et al., 2008;Chow and Ho, 2015;Meyer et al., 2015;Tuomola et al., 2016;Mahomed and Pretorius, 2020;Kabitsi and Powers, 2002)].This review suggests that cultural differences impact on patterns of help-seeking The impact of caring for family members with mental illnesses behaviour, access to sources of formal and informal support, the search for information about the mental illness and the motivation to provide family care (Kabitsi and Powers, 2002;Mahomed and Pretorius, 2020).For example, Mahomed and Pretorius (Mahomed and Pretorius, 2020) found that male South Africans in lowincome communities utilize a collective approach towards caregiving, relying on wider informal social networks instead of institutional and formal care services.Similar results were evident in studies that compared motives for family caregiving in Greece and America (Kabitsi and Powers, 2002).This study found that Greek and American carers were motivated by different factors.Greek families understood themselves in a more relational and largely family-interwoven frame, while American family carers were more motivated by financial reasons to provide family care.It can therefore be concluded that cultural differences in caregiving motivations may result in adaptive or maladaptive outcomes for the caregiver and care receiver.Here, studies suggest that cultural and religious values often correlate and overlap with one another.Several studies outlined the importance of religion and spirituality in helping family caregivers to manage the stress of caregiving [i.e.(Meyer et al., 2015;Robinson-Lane et al., 2021)].For example, Tuomola et al. (Tuomola et al., 2016), Chan (Chan, 2010) and Hinton et al. (Hinton et al., 2008) outlined how Confucian principles that highlight the importance of closeness between family members are reflected in family carers' reasoning processes.By drawing on the collectivistic cultures of East Asia that espouse a set of values and beliefs which promote maintenance of harmony with individuals and with the environment, family carers could overcome obstacles and emotional difficulties.Similar results are supported in Meyer et al.'s (Meyer et al., 2015) examination of Christian family carers who relied on their faith to cope with challenging situations.Community support and doctrinal beliefs about God's will helped caregivers to cope with distress and burden.In conclusion, the studies presented in this review suggest that it may be valuable to include an understanding of cultural values and an individual's spirituality and religion as components of tailored means of support for family caregivers.

DISCUSSION AND CONCLUSION
This scoping review was conducted to understand the effects of caring for family members with mental health illnesses on caregivers' wellbeing.The findings suggest that mental and physical wellbeing of family caregivers may depend upon a combination of situational and sociodemographic characteristics.
The review identified elderly, female and spousal primary-caregivers as a group who are at risk of experiencing mental and physical health.Primary caregivers, in comparison to secondary caregivers, suffer higher levels of distress, have less leisure time and smaller social circles.In addition, the findings indicate that there are gender differences that also need to be taken into consideration.The scoping review found that female spousal carers may view caring for their partner as their duty, try to be less dependent on support from others and take on multiple roles to fill the gaps that the mental illness of their partner has caused in comparison to their male counterparts, In doing so, female spousal carers may experience higher levels of distress and caregiver burden than male family caregivers.Spousal family caregivers often give up their work.This is linked to financial uncertainty and elevated levels of distress and depressive symptoms.In this sense, it is possible that some factors associated with caring for family members such as limited temporal resources may contribute to and trigger further stressors such as financial uncertainty.Similarly, elderly family caregivers tend to experience lower levels of wellbeing as they often do not have the stamina required for caring responsibilities, and experience diminishing social circles besides suffering from their own health issues.Therefore, the results suggest that for older caregivers, there are a range of underlying stressors that decrease the individual's overall quality of life and life satisfaction while increasing the burden of care.
Nevertheless, caregiving can also be a rewarding experience that fosters meaning, resilience and personal growth in the caregiver.Therefore, the present results suggest that the negative effects of caregiving can be balanced by the individuals' personality, social support, religiosity and culture.Specifically, high levels of agreeableness and extraversion in combination with social support relate to lower levels of caregiver stress and burden.Social resources were found to play a particularly important role because support from peers counteracts the loneliness and isolation that can lead to depression.In this sense, social resources combined with personality traits and social skills may be important in maintaining life satisfaction and quality of life.Also, positive attitudes towards life coupled with religious or spiritual beliefs helped improve the family caregivers' wellbeing because spirituality and religiosity provide a framework through which caregiving experiences can be interpreted in meaningful ways.This supports the idea that the meaningful interpretation of one's circumstances 18 R. Phillips et al.
is an important skill that can help give family caregivers a positive outlook on their life and understand difficult circumstances through multiple perspectives.However, despite the findings from this review, several limitations need to be taken into consideration.The present review did not examine demands, capabilities and meaning at the community level, nor did it consider the care receiver's adaptation and adjustment to their mental illness.The scoping review did not seek to assess the studies included regarding their quality or effect sizes.We also acknowledge that the sample of articles is skewed towards the challenges and demands of family caregivers for dementia (38 articles, 41.3%) and Alzheimer patients (13 articles, 14.13%).While the scholarship reviewed suggests that there is little difference in caregiver experience between conditions, it may still be possible that other unique aspects of the caregiver experiences in relation to other mental health illnesses have not been covered.In this sense, the present review included caregivers of individuals with different pathologies but did not necessarily differentiate between their experiences.Future research may therefore wish to focus on the experiences of family caregivers looking after an individual with specific mental health conditions such as depression or schizophrenia.In addition, as the care receiver's health can also influence the caregiver's quality of life, only few studies in the review discussed the caregivers' overall quality of life.This is problematic as it remains unclear whether the caregiver has lower self-rated quality of life besides scoring high on e.g.caregiver burden, and caregiver distress.This limitation can be addressed in future reviews focussing on examining and comparing specific measures such as self-rated quality of life.In addition, the scope of future reviews could include research that examines interventions intending to improve family caregivers' wellbeing.
Despite these limitations, the present review achieved its research objective by providing an overview of how family caregiving affects the caregivers physical, mental and social wellbeing, and the best ways to support family carers.While caregiving can have a negative impact on the physical and mental wellbeing of the carer, specific sociodemographic, personal and situational factors can work as a buffer.Therefore, support for family caregivers must be tailored to individual needs, taking into consideration personality, particular circumstances, along with cultural and personal beliefs.