Caregiver burden and coping strategies for patients with schizophrenia: Comparison between Japan and Korea

Authors


  • Field: (6) social psychiatry and epidemiology

Setsuko Hanzawa, PhD, School of Nursing, Jichi Medical University, Yakushiji 3311-159, Shimotsuke-shi, Tochigi 329-0498, Japan. Email: hanzawa@jichi.ac.jp

Abstract

Aim:  With the current shift to community-centered mental health services, considerable research on the family burden of caring for patients with schizophrenia has been conducted in developed countries. However, there has been no investigation of families with Japanese or Korean sociocultural backgrounds. Therefore, the present study compared the caregiver burden and coping strategies of families of patients with schizophrenia in Japan and Korea in order to elucidate similarities and differences in the sociocultural factors that affect the care experience of families in Northeast Asia.

Methods:  A total of 99 Japanese (Nagasaki) and 92 Korean (Seoul, Daegu) family members of patients with schizophrenia were surveyed in regards to caregiver burden, coping strategies, and nursing awareness of the caregiver role regarding the patient with schizophrenia.

Results:  Analysis revealed the following: (i) although no difference in caregiver burden and coping strategy was observed between the countries, the nursing awareness of families' caregiver role was significantly higher in Japan than in Korea; (ii) caregiver burden was significantly associated with the patient's social functioning and care needs in both countries; and (iii) caregiver burden was significantly associated with reduction of social interests, coercion, avoidance, resignation, and nursing awareness of caregiver role in both countries.

Conclusion:  Although the nursing awareness of families' roles in caring for patients with schizophrenia differed between Japan and Korea, similar trends were observed for the causes of caregiver burden. These findings suggest that in order to provide effective support for reducing caregiver burden, the necessity of such support must be emphasized in both countries.

THE LAST SEVERAL decades have produced two important lines of research involving families of persons with severe mental illness: one has focused on family burden and the experience of caring for an ill relative and the other on family communication patterns and interactions (e.g. expressed emotion). These lines of research have led to the development and testing of clinical models of family psycho-education.1 Previous research suggests that the level of caregiver burden is reduced when family members have a more positive attitude toward the patient and when there is an increase in social support, fewer hospitalizations, and improved social functioning of the patient.1

Recently, the factors influencing the extent of caregiver burden have attracted attention, and various caregiver characteristics, patient variables and regional differences have been identified as predictors of caregiver burden.2 Caregiver burden can also reflect regional differences regarding patients' socioeconomic situation and family support,3 as well as the provision of rehabilitative interventions for patients.4 Roick et al. reported that the burden placed on family members of people with schizophrenia may be influenced not only by patient and caregiver characteristics but also by national differences in the provision of mental health-care services.5 This assumption was evaluated by comparing Germany and Britain, two Northern European countries that differ appreciably in the provision of mental health services. Even after controlling for patient and caregiver characteristics, British caregivers reported a significantly higher level of burden than German caregivers.5 In another comparison study, higher burden was observed in Italy and Britain compared with the Netherlands, Spain and Denmark as a result of differences in the provision of mental healthcare services.6 Differences in caregiver burden could be caused by cultural characteristics, as cultures may differ in their appraisal of mental illness, ranging in attitude from acceptance and integration into society to stigmatization; religious beliefs, beliefs about the origin of mental illness, and society's appraisal of the caregiver's role also play a part.6

In addition, as the vast majority of previous studies were conducted in Western cultures, it has been difficult to apply their findings to family caregivers in Asian countries. In a sample of caregivers of family members with schizophrenia in Japan and England, Nomura et al. reported that expressed emotion did not correlate significantly with caregiver burden, and a decreasing tendency in caregivers' positive and negative emotional reactions towards family members, particularly critical comments in the Japanese sample, was observed.7 In our research in a Japanese population, we identified ‘resignation’ and ‘losing social interests’ as coping strategies that correlated significantly with caregiver burden in schizophrenia.8

East Asian cultures (Japan, Korea and China), based primarily on Confucian ideas, have traditionally emphasized the importance of providing care for dependents. Studies of Chinese families in Malaysia have demonstrated that the stigma of relatives' mental illness has a strong and pervasive impact on family caregivers, and as a result family caregivers often avoid talking about their relative's mental illness with extended family or friends in order to protect their families from ‘losing face’.9 In a recent study on caregiver burden in China, families who perceived a higher level of caregiver burden had poorer functioning, worse health status and lower satisfaction with social support, and social support was identified as the best predictor of caregiver burden.10 These results were similar to those obtained from our survey of Japanese families.11

A cross-cultural and cross-national comparison of caregiver burden between Japan and Taiwan showed that Japanese respondents perceived a significantly stronger stigma for the parents and neighbors of a person with a mental illness presented in a vignette than Taiwanese respondents.12,13 Haraguchi et al. reported that social distance, knowledge of mental illness, and treatment (medication) for mental illness were all higher in Japan than in China; the reasons for this include the fact that there are many advanced mental health-care inpatient facilities as well as regional rehabilitation services in Japan, and Japan formerly had a long-term hospitalization system and hospital detention policy (people with mental illnesses could be admitted involuntarily to a psychiatric hospital).14 In contrast, a recent study of Korea, Japan's closest neighbor, indicated that among relatives of patients with schizophrenia, those with less knowledge exhibited more inappropriate coping strategies and a higher burden.15

In Japan, where the institutionalization rate for schizophrenia patients is the highest in the world, the number of psychiatric beds has not decreased, while in Korea, a steady increase in the number of psychiatric beds has been observed over the past 10 years.16 However, little is known about the correlation between caregiver burden for families of patients with schizophrenia in Northeast Asian countries and sociocultural factors, which may differ from country to country in the appraisal of the caregiver's role and coping strategies. Therefore, it is important to compare Japan and Korea to identify differences in sociocultural background that could contribute to differences in caregiver burden in these two countries.

The following research points regarding intercultural aspects formed the focus of the present study. First, the tendency for Japanese families to exhibit decreased emotional expression towards family members as compared to Korean families was explored. Second, differences in religious beliefs and beliefs about the origin of mental illness and in appraisal of the caregiver's role were identified through cross-cultural comparison of Japan and Korea, emphasizing the history of hospitalization and cultural differences.

METHODS

Subjects

The purpose and methods of the study were explained in advance at the general meeting of the Federation of Families of People with Mental Illness in Nagasaki, Japan and in Seoul and Daegu, Korea. During the meeting, 13 local family groups for mutual support in Nagasaki and 12 local family groups for mutual support in Seoul and Daegu agreed to participate in the study. Before conducting the survey, all participants received a written explanation about the purpose of the study and provided informed consent to participate. A total of 162 family members in Nagasaki and 125 family members in Seoul and Daegu gave consent to participate and were included in the study. The study was conducted from October 2004 to March 2005 in Nagasaki and from October 2007 to March 2008 in Seoul and Daegu. The study protocol was approved by the Ethics Committee of Nagasaki University Graduate School of Biomedical Sciences (Approval no. 15111258).

Subjects were from 99 families in Nagasaki and 92 families in Seoul and Daegu. All subjects were family members of a patient who was diagnosed with schizophrenia according to the ICD-10 diagnostic criteria.17 If a family was caring for two or more patients, they were asked to fill out the questionnaire with respect to the patient who required the greatest level of care.

Questionnaire

The questionnaire consisted of three sections. Section 1 collected patient-related information on the demographic features of the participants: age, gender, total number of hospitalizations, and occupation (employment/workshop/day-care center) and the patient's social functioning and care needs. Section 2 collected family-related information: age, family relationship to the patient and whether the respondent lived with the patient. Section 3 consisted of self-rated questions relating to caregiver burden, coping strategies and nursing awareness of the caregiver's role.

In the present study, caregiver burden was assessed using the eight-item short version of the Zarit Caregiver Burden Interview (ZBI-8).8,18–24 The ZBI-8 consists of eight questions graded using a five-point Likert scale (0–4 points), with higher scores representing increased caregiver burden.

The 23-item Family Coping Questionnaire (FCQ-23)25 was used to rate coping strategies on seven subscales: information acquisition, positive communication, social interest, coercion, avoidance, resignation, and patient's social involvement. The FCQ-23 consists of 23 questions graded using a four-point Likert scale (1–4 points), with higher scores indicating better coping strategies.

The seven-item Nursing Awareness Among Caregivers Scale (NA-7)26 was used to rate family members' awareness of the caregiver's role. For this scale, seven items were evaluated using a four-point Likert scale (1–4 points), with lower scores indicating higher awareness of the caregiver's role.

Korean translations of the J-ZBI-8, FCQ-23 and NA-7 were administered to the Korean participants. Each item was first translated by Korean members of our research project, one of whom has 10 years of experience working in a Japanese university. Another Korean member, a research assistant at Daegu University, checked the accuracy of the translated questionnaires.

Statistical analyses

Caregiver burden was compared among families with different sociodemographic backgrounds using a t-test (for comparisons between two groups) and analysis of variance (for comparisons among three or more groups). In addition, caregiver burden, coping strategies, and nursing awareness were compared between Japan (Nagasaki) and Korea (Seoul and Daegu) using a t-test. Relationships between caregiver burden and other factors were then investigated using multiple regression analysis with burden of care as the dependent variable after deriving Spearman's rank-order correlation coefficients. spss 12.0 for Windows (spss, Chicago, IL, USA) was used for all statistical analyses. The level of statistical significance was set at less than 5%.

RESULTS

Sociodemographic characteristics and caregiver burden

Table 1 shows the sociodemographic characteristics of patients and families for the Japanese and Korean surveys.

Table 1.  Sociodemographic characteristics
 Japan
(n = 99)
Korea
(n = 92)
n% Pn% P
  • Spearman.

  • anova.

  • §

    § t-test.

Patients        
 Age        
  Mean (SD)38.5(9.5) r = −0.1760.09335.8 (8.1) r = −0.2220.034
 Gender        
  Male7474.7t = −1.5610.1226570.7t = 0.4130.681§
  Female2525.3  2729.3  
 Total number of hospitalizations        
  02121.2F = 0.9320.46544.3F = 0.6560.658
  12929.3  99.8  
  21515.2  2426.1  
  31313.1  1617.4  
  477.1  1314.1  
  5+1414.1  2628.3  
 Total years of hospitalization        
  02020.2F = 0.9860.44066.5F = 0.5650.757
  <13333.3  4447.8  
  <32020.2  2223.9  
  <51010.1  88.7  
  <1088.1  88.7  
  <1522.0  11.1  
  <2000.0  33.3  
  <3012.0. 00.0  
  >3000.0  00.0  
 Current treatment status        
  Inpatient11.0t = −0.8750.38477.6t = −1.1300.299§
  Outpatient9090.9  8592.4  
 Social involvement        
  Employment22.0F = 1.9490.09422.2F = 1.4350.220
  Part-time employment44.0  22.2  
  Workshop & Day care4242.4  5357.6  
  Able to help around the house1111.1  88.7  
  Unable to help around the house and sometimes goes outside1818.2  1617.4  
  Unable to help around the house and doesn't go outside1515.2  1112.0  
 Patients' social function and care needs        
  Able to behave ordinarily in their daily or social lives2424.2F = 7.8900.0002729.3F = 7.3030.000
  Occasionally requires support due to certain limitations3434.3  4447.8  
  Occasionally requires support due to serious limitations1818.2  1213.0  
  Usually requires support due to serious limitations1313.1  66.5  
  Always requires support because unable to perform in daily or social lives33.0  33.3  
 Age        
  Mean (SD)65.0 (8.2) r = −0.1130.27759.7 (11.7) r = −0.0220.834
 Relationship        
  Father1818.2F = 0.6130.6902223.9F = 0.3150.927
  Mother7171.7  5458.7  
  Husband11.0  33.3  
  Wife22.0  33.3  
  Daughter00.0  22.2  
  Son11.0  11.1  
  Other11.0  77.6  
 Living with patient8484.8t = −0.1710.8658390.2t = −1.1730.272§
 Alternative carer4747.5t = −0.0020.9982628.3t = −1.0010.316§

In both Japan and Korea, approximately 70% of patients were men. The mean age of patients was 39 years in Japan and 36 years in Korea. In Korea, patient age was found to be associated with burden of care (P < 0.05). A total of 21% and 4% of Japanese and Korean patients, respectively, reported no previous hospitalization. Approximately half of the patients regularly visited workshops or day-care centers for disabled individuals. The proportion of patients who occasionally required support due to limitations in their daily or social lives was 35% in Japan and 48% in Korea. In both countries, patients' social functioning and care needs were found to be associated with caregiver burden.

The mean age of family members was 65 years in Japan and 60 years in Korea. A total of 72% and 59% of Japanese and Korean family members, respectively, were mothers. Approximately 90% of families lived with patients in both countries. A total of 48% and 28% of Japanese and Korean families, respectively, had alternative caregivers.

Evaluation of burden of care, coping strategies and nursing awareness

Table 2 shows the results from the burden of care, coping strategies, and nursing awareness for the Japanese and Korean surveys.

Table 2.  ZBI-8, FCQ-23, and NA-7 scores for Japan and Korea
 Japan
(n = 99)
Korea
(n = 92)
tP
MeanSDMeanSD
  • *

    P < 0.05;

  • **

    P < 0.01;

  • ***

    P < 0.001.

  • FCQ-23, Family Coping Questionnaire; NA-7, seven-item Nursing Awareness Among Caregivers Scale; ZBI-8, the 8-item short version of the Zarit Caregiver Burden Interview.

ZBI-811.08.010.37.0−0.6820.496
 Do you feel embarrassed over your relative's behavior?1.91.21.51.3−2.5590.011*
 Do you feel angry when you are around your relative?1.51.21.51.00.1350.893
 Do you feel that your relative currently affects your relationship with other family members or friends?1.31.31.31.2−0.3080.758
 Do you feel strained when you are around your relative?1.51.31.21.2−1.9200.056
 Do you feel that your social life has suffered because you are caring for your relative?1.01.31.21.21.1850.237
 Do you feel uncomfortable about having friends over because of your relative?1.41.51.21.2−1.0440.298
 Do you wish you could just leave the care of your relative to someone else?1.11.30.81.2−1.4460.150
 Do you feel uncertain about what to do about your relative?1.61.21.71.20.3310.741
FCQ-2365.68.167.88.41.8070.072
 Information5.11.65.71.72.3240.021*
 Positive communication12.83.514.03.32.3780.018*
 Social interests10.62.310.42.5−0.5050.614
 Coercion15.72.515.12.8−1.5750.117
 Avoidance10.91.610.91.7−0.1240.901
 Resignation6.31.96.11.9−0.5590.577
 Patient's social involvement4.41.75.71.75.3590.000***
NA-716.76.320.94.55.1080.000***
 I want care to be provided only by family members as much as possible2.41.32.81.22.2640.025*
 I do not feel comfortable with having someone outside the family take care of the individual2.61.23.41.05.0990.000***
 I am reluctant to have others take care of the individual because it is my responsibility2.61.22.91.21.3500.179
 The individual seems to feel uncomfortable with others entering his/her house2.31.22.91.13.5580.000***
 The individual seems to feel uncomfortable with being cared for by someone outside the family2.11.12.81.14.2450.000***
 My other family members do not feel comfortable with having others take care of the individual2.41.12.91.13.0220.003**
 I am concerned about what my relatives and neighbors might think2.51.13.31.05.2460.000***

For the ZBI-8, Cronbach's alphas were high, at 0.91 in Japan and 0.88 in Korea. ZBI-8 scores ranged from 1 to 32; the mean total score was 11.0 (SD = 8.0) in Japan and 10.3 (SD = 7.0) in Korea. There was no significant difference between Japan and Korea in mean ZBI-8 score. Table 2 shows the distribution of response scores for each item. Responses with mean scores that were higher in Japan than in Korea included ‘Do you feel embarrassed by your relative's behavior?’ (P < 0.05).

For the FCQ-23, Cronbach's alphas were moderately high, at 0.74 in Japan and 0.77 in Korea. The mean total scores were 65.6 (SD = 8.1) in Japan and 67.8 (SD = 8.4) in Korea. The mean FCQ-23 score was not significantly different between Japan and Korea. Table 2 shows the distribution of response scores for each item. Responses with mean scores higher in Korea than in Japan included ‘social involvement’ (P < 0.001).

For the NA-7, Cronbach's alphas were high, at 0.89 in Japan and 0.66 in Korea. The mean total scores were 16.7 (SD = 6.3) in Japan and 20.9 (SD = 4.5) in Korea. The mean NA-7 score was significantly lower in Japan than in Korea (P < 0.001). In the distribution of response scores for each item, responses with mean lower scores in Japan than in Korea included ‘I want care to be provided only by family members as much as possible without using home help services’ (P < 0.05), ‘I do not feel comfortable having someone outside the family take care of the individual’ (P < 0.001), ‘The individual seems to feel uncomfortable with others entering his/her house’ (P < 0.001), ‘The individual seems to feel uncomfortable being cared by someone outside the family’ (P < 0.001), ‘My other family members do not feel comfortable with having others take care of the individual’ (P < 0.01), and ‘I am concerned about what my relatives and neighbors might think’ (P < 0.001).

Factors related to caregiver burden

Correlations between ZBI-8 score and other factors, such as coping strategies and nursing awareness, are summarized in Table 3. Significant correlations with ZBI-8 score were observed for the total coping strategy score in both countries (P < 0.01 in Japan, P < 0.001 in Korea). Regarding individual scores for the subscales of coping strategies, in both countries, correlations with ZBI-8 score were observed for ‘social interests’ (P < 0.01 in Japan, P < 0.001 in Korea), ‘coercion’ (P < 0.001 in Japan, P < 0.001 in Korea), ‘avoidance’ (P < 0.001 in Japan, P < 0.001 in Korea), and ‘resignation’ (P < 0.001 in Japan, P < 0.001 in Korea).

Table 3.  Correlations between ZBI-8 and other scales for Japan and Korea
 Japan
(n = 99)
Korea
(n = 92)
rPrP
  • *

    P < 0.05;

  • **

    P < 0.01;

  • ***

    P < 0.001 (Spearman).

  • FCQ-23, Family Coping Questionnaire; NA-7, seven-item Nursing Awareness Among Caregivers Scale; ZBI-8, the 8-item short version of the Zarit Caregiver Burden Interview.

FCQ-23−0.3300.001**−0.4540.000***
 Information0.1430.1730.1660.113
 Positive communication0.0740.482−0.1240.240
 Social interests−0.2710.009**−0.3490.001**
 Coercion−0.4370.000***−0.4000.000***
 Avoidance−0.5820.000***−0.4350.000***
 Resignation−0.6520.000***−0.3930.000***
 Patient's social involvement0.1590.126−0.1710.104
NA-7−0.0420.7050.0220.838
 I want care to be provided only by family members as much as possible0.2750.008**0.1630.121
 I do not feel comfortable with having someone outside the family take care of the individual0.0510.631−0.1320.209
 I am reluctant to have others take care of the individual because it is my responsibility0.1240.2380.3500.001**
 The individual seems to feel uncomfortable with others entering his/her house−0.2200.035*−0.2410.020*
 The individual seems to feel uncomfortable with being cared for by someone outside the family−0.3100.003**−0.2280.029*
 My other family members do not feel comfortable with having others take care of the individual−0.0780.4670.2080.046*
 I am concerned about what my relatives and neighbors might think−0.1370.192−0.1330.206

Multiple regression analysis using ZBI-8 scores as dependent variables

Results of the multiple regression analysis are summarized in Table 4.

Table 4.  Multiple regression for ZBI-8 as a dependent variable for Japan and Korea
Independent variableJapan
(n = 80)
Korea
(n = 91)
βtPβtP
  • *

    P < 0.05;

  • **

    P < 0.01.

  • β, standardized regression coefficient; FCQ-23, Family Coping Questionnaire; NA-7, seven-item Nursing Awareness Among Caregivers Scale; R, multiple correlation coefficient; ZBI-8, the 8-item short version of the Zarit Caregiver Burden Interview.

Patient's age   −0.197−2.5580.012*
Patient's social function and care needs0.2162.5960.011*0.1992.3350.022*
FCQ-23      
 Social interests−0.061−0.7510.455−0.193−2.2680.026*
 Coercion−0.181−2.1340.036*−0.244−2.7430.007**
 Avoidance−0.169−1.9360.057−0.269−2.9180.005**
 Resignation−0.352−3.5820.001**−0.140−1.6300.107
NA-7      
 I want care to be provided only by family members as much as possible0.1031.1830.241   
 I am reluctant to have others take care of the individual because it is my responsibility   0.0220.2220.825
 The individual seems to feel uncomfortable with others entering his/her house0.1891.4600.149−0.091−1.0300.306
 The individual seems to feel uncomfortable with being cared for by someone outside the family−0.342−2.6560.010*−0.114−1.2300.222
 My other family members do not feel comfortable with having others take care of the individual   0.2042.1730.033*
 R 0.796  0.767 
 R2 0.633  0.588 

Multiple regression analysis of the data from Japanese participants was performed using variables that were significantly associated with caregiver burden (patient's social functioning and care needs, social interests, coercion, avoidance and resignation subscales of coping strategies, and the three individual scores of nursing awareness) as independent variables and caregiver burden as the dependent variable. Caregiver burden was found to be significantly associated with the patient's social functioning (P < 0.05), the coercion and resignation subscale of coping strategies (P < 0.05), and ‘The individual seems to feel uncomfortable being cared for by someone outside of the family’ as a factor of nursing awareness (P < 0.05).

Multiple regression analysis of the data from Korean participants was performed using variables that were significantly associated with caregiver burden (patient's age, social functioning and care needs, social interests, coercion, avoidance and resignation subscales of coping strategies, and the four individual scores of nursing awareness) as independent variables and caregiver burden as the dependent variable. Caregiver burden was significantly associated with patient's age (P < 0.05), social functioning and care needs (P < 0.05), social interests (P < 0.05), coercion (P < 0.01), avoidance (P < 0.01), and ‘My other family members do not feel comfortable with having others take care of the individual’ as a factor of nursing awareness (P < 0.05).

DISCUSSION

The results of the present study clarified similarities and differences in the characteristics of patients with schizophrenia and their families who belong to family support groups in Japan and Korea.

Several differences between patients in Korea and Japan were observed. For example, when compared to Japanese patients, Korean patients were younger, and in Korea, the younger the patient, the greater the caregiver burden. In addition, the proportion of Japanese and Korean patients who were frequently hospitalized (at least three times) was 34.3% and 59.8%, respectively; clearly, Korean patients with schizophrenia were hospitalized more frequently over short periods of time. There were also differences between the two countries in social activities over the past year and the levels of living skills and care needs. In the present study, Korean patients were younger, had more opportunities to go out during the day and exhibited less impairment in activities of daily living as compared to Japanese patients. However, Korean patients were hospitalized more frequently and their families more strongly encouraged social participation. A multiple regression analysis in a previous study identified the number of hospitalizations in the previous 3 years and kinship (mother/father/other) as significant predictors of caregiver burden.24 The present results did not identify the total number of hospitalizations in the previous year as a significant predictor in either country; however, patient's social function and care needs were both identified as significant predictors of caregiver burden in both Japan and Korea.

The results of the present study also suggest that when compared to Korean families, nursing awareness of the caregiver's role in Japanese families (‘I want care to be provided only by family members as much as possible’) was significantly greater; however, in both countries, family caregiver burden was significantly correlated with nursing awareness of the fact that ‘The individual seems to feel uncomfortable with being cared by someone outside the family’. In other words, in both countries, patients with schizophrenia are likely to avoid contact with non-family members and isolate themselves from society, and these factors are related to the degree of family caregiver burden.

In a study comparing five European countries, regional differences were identified in caregiver burden and support inside and outside the family.27 The present results demonstrated slight differences in independent factors for caregiver burden between Japan and Korea. In Japan, families who agreed with the statement ‘The individual seems to feel uncomfortable with being cared for by someone outside the family’ were more likely to have greater caregiver burden. In Korea, family members who agreed with the statement ‘My other family members do not feel comfortable with having others take care of the individual’ were more likely to have low caregiver burden. The results from Korea suggest that when other family members also think that a patient with schizophrenia should be cared for by family, family members are more likely to collaborate in order to reduce caregiver burden. However, 70% of Korean families did not have someone who could provide care, which was a higher proportion than that observed in Japan. These findings suggest that, in Korea, it is difficult for family members to find caregivers who can provide care on behalf of the family, despite the fact that Confucian ideas and the tradition of providing care to family members contribute to the reduction of caregiver burden.

The present results clarified that, while caregiver burden is high in both Korea and Japan, patients and family members have a strong desire to restrict care to family members. This issue should be discussed further, especially in relation to the quality of community mental health-care services, in order to reduce family caregiver burden; e.g. general practitioners, home-visit nurses, home-help service providers, mutual support group members, other outreach services, and integrated assertive community services should provide advice for families having difficulties finding treatment and should suggest coping strategies for patients, especially during relapse of illness. Early intervention may be an effective form of support for the first episode of schizophrenia.

Limitations and future studies

First, although the reliability and validity of each questionnaire used in the present study have been confirmed in Japan,8 the reliability of the Korean version has not been sufficiently investigated. Second, as participants lived only in Nagasaki, Seoul or Daegu, our target population is therefore not representative of the general populations of Japan and Korea. A comparative study of national surveys across different cultures requires more in-depth studies in both countries. In particular, further investigation of factors influencing the stigmatization of schizophrenia and its effect on the families of patients with schizophrenia is therefore necessary. In order to design more effective family and community support programs, we plan to address these issues in future studies.

ACKNOWLEDGMENTS

This study was conducted as part of a research project entitled ‘Sociocultural and natural-environmental factors related to the burden for families of patients with schizophrenia’, which was supported by a Grant-in-Aid for Scientific Research (KAKENHI) (C) (19592603) (2007-09) from the Japanese Ministry of Education, Culture, Sports, Science and Technology (MEXT). The authors deeply appreciate the cooperation of the members of the Federation of Families of People with Mental Illness in Nagasaki and Seoul and Daegu, without which the study would never have been completed.

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