Contents lists available at ScienceDirect Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp Coping with caregiving stress among caregivers of patients with schizophrenia Pradyumna Rao, Sandeep Grover*, Subho Chakrabarti Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India ARTICLE INFO Keywords: Coping Schizophrenia Caregivers ABSTRACT This study aimed to evaluate the coping strategies, including religious coping, used by the caregivers of patients with schizophrenia to deal with caregiving stress. Caregivers of 100 patients with schizophrenia, currently in clinical remission, were evaluated on Ways of the coping questionnaire, Brief religious coping scale, and General Health Questionnaire (GHQ-12). More often use of adaptive coping mechanisms (such as seeking social support, accepting responsibility, planful problem solving, and positive reappraisa) was associated with a lower level of residual symptoms and better functioning of the patient, and lower level of psychological morbidity as per the GHQ-12 among the caregivers. A higher grade of negative symptoms, general psychopathology, and PANSS total score was associated with lower use of positive religious coping and higher use of negative religious coping in the caregivers. More severe psychological morbidity among the caregivers was associated with lower use of positive religious coping and higher use of negative religious coping. To conclude, this study depicts that caregivers of patients with schizophrenia use a mixture of adaptive and maladaptive coping strategies, including religious coping. The use of adaptive coping is associated with better patient-related outcomes and lower levels of psychological morbidity/distress among caregivers. Whereas, more frequent use of maladaptive coping is associated with both patients' and caregivers' outcomes. 1. Introduction Schizophrenia is an illness that not only places a considerable burden on the afflicted individuals but also poses a significant challenge to their caregivers. Those caregivers of patients with schizophrenia who are unable to cope with the overwhelming caregiving distress, develop psychological morbidity, and reduced quality of life. The dominant paradigm which tries to explain the caregiving pro- cess includes the stress-appraisal-coping (or the stress-coping), which was put forth by Lazarus and Folkman to explain the process of coping with stress (Lazarus and Folkman, 1984). This model has been subse- quently adopted by other researchers to explain caregiving's process among family members of those with chronic psychiatric disorders (Scazufca and Kuipers, 1999; Hassan et al., 2011; Kate et al., 2013a; Hegde et al., 2019). This model assumes that taking care of a person with mental illness is stressful for the caretaker. The patients' problem- behaviors, disabilities, and the burden caused by them constitute the significant stress that caregivers face, and appraisal of these stresses calls for different coping mechanisms. An estimate is understood as evaluative judgments of the caregivers and can be primary (i.e., de- mands of the caregiving situation), or secondary (the adequacy of coping resources) appraisal. Mediators of appraisal and coping strategies include attributes of the caregiver’s, i.e., demographic and personality characteristics, socio- cultural factors, and the degree of social support. The eventual out- come, i.e., distress or well-being of the caregivers, is determined by the interaction between the stressors, appraisal of the stress, and coping strategies used. When coping is ineffective in reducing the appraised stress, this results in physical or psychological distress for the caregiver (Magliano et al., 1995; Scazufca and Kuipers, 1999; Grover et al., 2015). When one carefully looks at this model, it becomes evident that coping is an important determinant that influences the psychological state of the caregivers. Hence, accordingly, improving adaptive coping can lead to improved outcomes of the caregivers and possibly that of patients. Coping is the process of managing taxing or overwhelming demands (external or internal) on the person (Lazarus and Folkman, 1984). Coping mechanisms are classified in many ways, and some of the popular categories include adaptive versus maladaptive, positive versus negative coping, and problem-focused coping and emotion-focused coping. Additionally, it suggested that many persons also use religious coping to deal with stress. Religious coping is a multidimensional https://doi.org/10.1016/j.ajp.2020.102219 Received 19 April 2020; Received in revised form 27 May 2020; Accepted 9 June 2020 ⁎ Corresponding author. E-mail address: drsandeepg2002@yahoo.com (S. Grover). Asian Journal of Psychiatry 54 (2020) 102219 1876-2018/ © 2020 Published by Elsevier B.V. T