








































Graduate Student Journal of Psychology                                                                             Copyright 2005 by the Department of Counseling & Clinical Psychology 


Graduate Student Journal of Psychology                                                                             Copyright 2006 by the Department of Counseling & Clinical Psychology  
2006, Vol. 8                                                                                                                          Teachers College, Columbia University                          ISSN 1088-4661 
 
 
 

Spouse Caregivers and Dementia Relationships 
 
 

Chari I. Hirshson 
Ferkauf Graduate School of Psychology 

Yeshiva University 
 

A review of the literature shows an association between depression and perceived burden in care-
givers of dementia patients. These caregivers are often the spouses of cognitively impaired elders, 
and they experience an emotional toll with negative effects on their mental health and well-being. 
Findings from past research focus on spouses as caregivers and the influences of primary and 
secondary stressors on their depressive mood symptoms. The experiences of male caregivers with 
demented spouses differ from those of female caregivers with demented spouses, suggesting that 
either the gender of the patient, the gender of the caregiver, or both affect the experience of care-
giving. The potential reasons for this difference are highlighted and compared. Implications for 
future work are discussed, such as the need to create and research interventions and assessments 
that can recognize and reduce caregiver burden and depression.  
 

 
Depression in Caregivers of Dementia Patients 

 
Dementia poses a significant public health problem be-

cause of the debilitating and progressive nature of the de-
cline. Problematic aspects associated with dementia include 
the loss of independence, social limitations and interper-
sonal withdrawal, and personality and/or behavior changes 
that result from cognitive, behavioral and affective losses in 
functioning (Moritz, Kasl & Berkman, 1989).   

Dementia affects more than just the patient – it can 
negatively impact the people that bear the responsibility for 
their care. It is estimated that 8.5 million people care for a 
dementia patient at home (Gallicchio, Siddiqi, Langenberg, 
& Baumgarten, 2002). Caregivers within this population 
experience considerable psychological and physical mor-
bidity (Dunkin & Anderson-Haley, 1998), with the most 
consistent and deleterious of these effects experienced in 
the mental health domain (George, 1994).  

Caregivers for demented patients versus non-demented 
patients experience higher levels of strain and burden due to 
the nature of dementia symptoms, such as wandering, 
screaming, and destroying property (Ory, Hoffman, Yee, 
Tennesedt, Schulz, 1999; Schulz, O’Brien, Bookwala, 
Fleissner, 1995). Primary stressors affecting the caregiver 
(such as feelings of loss in the marital relationship, func-
tional capabilities of the impaired, and the impaired’s level 

 
Chari I. Hirshson is a PhD candidate in clinical psychology at 
Albert Einstein College of Medicine/Yeshiva University, Ferkauf 
Graduate School.  

Correspondence concerning this article should be addressed 
to Chari I. Hirshson, Ferkauf Graduate School, Yeshiva Univer-
sity, 1165 Morris Park Avenue, Bronx, NY 10461; email:  
charicohen@gmail.com.

of problem behaviors) combined with secondary contextual 
factors associated with the caregiver (sociodemographic, 
gender, and economic strain) have been correlated with 
negative caregiver outcomes (Bookwala & Schulz, 2000; 
Moritz et al., 1989; Whitlatch, Schur, Noelker, Ejaz, & 
Looman, 2001).  

Dementia caregivers are negatively affected by “em-
ployment complications, caregiver strain, mental and physi-
cal health problems, time for leisure and other family mem-
bers, and family conflict” (Ory, et al., 1999, p. 184). Nega-
tive symptoms arising from the caregiving situation can 
include significant distress (Karlawish, Casarett, Klocinski, 
& Clark, 2001), poor psychological well-being (Schulz et al., 
1995), depression and anxiety, medical problems, and dete-
rioration in occupational and social functioning (Chentsova-
Dutton et al., 2002).  

In the research on this topic, the terms caregiving burden 
and caregiving impact are often used interchangeably, al-
though the two concepts are distinct. Impact is used to de-
scribe the change in the caregiver’s life, such as health, social 
activities, occupation and familial relationships. Burden 
describes the subjective experience of caregiving tasks 
(Moritz et al., 1989). Distinguishing between these similar 
terms is imperative in clarifying the findings of various 
studies.  

In addition to the importance of differentiating between 
burden and impact, there is evidence of a difference in ex-
perience between male and female caregivers, and under-
standing this gender difference is an important aspect of 
understanding caregiving depression. There have been incon-
sistent findings in the literature regarding gender differences 
in terms of depression and caregiver burden with demented 
patients (Gallicchio et al., 2002). Select studies indicate that 
female caregivers are more likely to report greater burden 
(Miller & Cafasso, 1992; Yee & Schulz, 2000), while other 

19 



HIRSHSON 
 

20 

studies have failed to find gender differences (Hinrichsen & 
Niederehe, 1994; Shields, 1992).  

The discrepancy among the results may be attributed to 
women constituting 73% of the caregiving population (Ory et 
al., 1999), yielding an over-representation of women in 
caregiving research. Differences in study designs, including 
lack of control groups, may have created results that suggest 
a greater impact upon women rather than men in the caregiv-
ing role (Moritz et al., 1989). This contradiction points to a 
need to further examine gender differences in the effects of 
caregiving. Both the caregiving experience and the interper-
sonal relationship between the caregiver and their demented 
spouse need to be considered.  

The effects of caregiving for a patient with dementia 
have not been systematically reviewed. Accordingly, the 
existing literature is scattered and unable to provide a com-
plete and representative picture of the experience of a demen-
tia caregiver. The goal of this review is to examine critically 
caregiver depression and burden, investigating the emotional 
experiences of spousal caregivers of dementia patients. The 
investigation into this matter will consider different studies 
and meta-analyses that have identified specific stressors and 
predictors of caregiver depression and evaluated gender 
differences among caregivers. Further, the review will inter-
pret theoretical and practical implications of caregiver de-
pression for designing interventions and educational pro-
grams. 

 
General Differences Among Caregivers and Caregiving 

Situations 
 
Data shows that dementia caregivers experience varying 

levels of distress in their response to the challenge of caregiv-
ing. Two classes of primary stressors affect the caregiver’s 
mental health: the level of impairment of the patient and 
involvement of the caregiver in the caregiving situation 
(Miller & Cafasso, 1992; Bookwala & Schulz, 2000). Secon-
dary variables, which are defined as the stressors that are 
triggered because of the primary caregiving stressors, include 
the caregiver’s relationship to the patient (Schulz et al., 1995) 
and attributional style (Stull, Kosloski, Kercher, 1994; Schulz 
et al., 1995). 

 
Primary Stressors: Level of Impairment and Involve-

ment of the Caregiver 
 
According to the meta-analysis of correlates of psychiat-

ric morbidity in caregivers by Schulz and colleages (1995), a 
number of patient characteristics were unrelated to caregiver 
distress, but the one patient characteristic that powerfully 
predicted caregiver depression was the degree to which the 
dementia patient experienced problem behaviors. Problem 
behaviors, which include wandering, screaming, and destroy-
ing property, are generally a result of a decrease in the cogni-
tive functioning of the patient and the increase in the level of 
severity of the illness. Evidence of such problem behaviors in 

the patient predicted caregiver depression (Schulz et al., 
1995) and poor coping mechanisms of the caregiver 
(Hinrichesen & Niederehe, 1994). 

Moritz et al. (1989) found living with a cognitively im-
paired elderly spouse negatively affected the health and well 
being of the caregiver. Male caregivers exhibited an increase 
in depressive symptoms as their wives’ level of cognitive 
functioning decreased. However, the reverse was not the 
case, as wives did not show a significant relationship be-
tween cognitive functioning in their husbands and their own 
levels of depression and perceptions of burden.  

In at least some caregiving situations, however, the level 
of the severity of impairment and evidence of problem be-
haviors were implicated as predictors of caregiver depres-
sion. The findings underscore the importance of recognizing 
problem behaviors and seeking additional help when these 
behaviors arise.  

 
Secondary Stressors: Attributional Style and Relation-

ships of the Caregiver 
 

The analyses thus far encourage further understanding of 
the etiology of caregiver depression. Are specific individuals 
more resilient to stress and burden in the caregiving situa-
tion? Are there personal attributes of the caregiver, or an 
attributional style, that allow one to persist longer in this role 
than others or cause an individual to seek support or treat-
ment? Attributional style refers to the way a person deter-
mines which forces they hold responsible for successes and 
failures. For our purposes, attributional style in caregiving 
refers to the way a caregiver perceives the caregiving situa-
tion.  

Psychosocial and personality variables predictive of de-
pression in caregivers have not been fully identified (Dunkin 
& Anderson-Haley, 1998). However, specific attributes of 
the caregiver are predictive of the caregiving outcome. This 
includes the feeling of perceived enrichment in the care-
giver’s life and the caregiver’s ability to find personal mean-
ing through his or her relationship (Stull et al., 1994). Con-
versely, it is also possible that caregivers’ attributional styles 
can leave them more vulnerable to depression, as caregivers 
may have basic assumptions about caregiving being burden-
some. Therefore, they may have a preconceived belief re-
garding how they are supposed to feel about providing care.   

The attributional style of the caregiver in terms of other 
relationships has been evaluated in the literature and judged 
to be of importance. In addition, the presence of a strong 
social network for the caregiver was protective, and satis-
faction with this support was predictive of positive out-
comes (Dunkin & Anderson-Haley, 1998). Furthermore, the 
quality of the relationship between the caregiver and the 
patient has been shown to impact the level of depression 
and/or burden experienced within the caregiving situation 
(Schulz et al., 1995). Tower and colleagues (1997) found 
that closeness of the spousal relationship moderated the 
impact of depressive symptoms of male caregivers whose 



DEPRESSION IN SPOUSAL CAREGIVERS 
 

21 

wives were cognitively impaired. Those whose marriages 
were described as being closer prior to the cognitive im-
pairment were more affected by depressive symptoms than 
those who were less close before the onset of their spouse’s 
dementia. However, this result was found with male care-
givers only. Female caregivers’ levels of depression were 
not significantly associated with their husbands’ levels of 
cognitive impairment, regardless of the strength of the 
spousal relationship. 

Beeson and colleagues (2000) hypothesized that in-
creases in loneliness and depression in the caregiver re-
sulted from experiencing the loss of closeness in the rela-
tionship due to cognitive changes in the patient. They found 
that caregivers who experienced higher loneliness and de-
pression also experienced higher levels of relational deprav-
ity and a higher dissatisfaction with the lower quality of the 
current relationship with the patient. In contrast to Tower 
and colleagues (1997), Beeson and colleagues (2000) found 
that female spouse caregivers reported a significantly 
higher level of relationship depravity, loneliness and de-
pression than the daughter caregivers. Thus suggests that  
the nature of the relationship between the caregiver and the 
care receiver is important in determining likelihood of care-
giver depression and subsequent quality of the relationship 
between the caregiver and demented family member. 

 
Gender Differences and Gender Role Socialization in 

the Caregiving Experience 
 

Previous research has examined gender as a variable 
relative to caregiver depression, yet results have been in-
consistent as to the effect of gender. Is it possible that gen-
der can be a risk or protective factor for caregiver depres-
sion? Yee and Schulz (2000) compiled a review of empiri-
cal research from 1985 to 1998 on caregiver differences in 
psychiatric morbidity in terms of gender, including depres-
sion as an index measure. In investigating gender differ-
ences in caregiving with the elderly (physically ill and de-
mented adults), the authors found higher distress in female 
caregivers versus male caregivers. The 30 articles reviewed 
suggested that women exhibit more psychiatric symptoms 
than men, specifically on the domains of depression, anxi-
ety, general psychiatric symptoms and lower life satisfac-
tion. Compared to women who are not in the caregiving 
role, caregiving women experience more psychiatric mor-
bidity attributable to caregiving. It is suggested that women 
have a greater susceptibility to psychiatric morbidity then 
men because they respond differently to all stages of stress. 
In addition, men do not tend to engage in behaviors that 
would put them at a greater risk for psychiatric morbidity. 
For example, they are more likely than women to seek addi-
tional help or relinquish the caregiving role (Yee and 
Schulz, 2000). 

Conversely, more recent research has suggested a dif-
ferent gender effect. Gallicchio and colleagues (2002) in-
vestigated the relationship of gender, burden and depression 
among 259 female and 68 male caregivers working with the 

dementia population. They found female caregivers to have 
a significantly higher risk of experiencing caregiver burden 
and stress. On average, women reported greater burden than 
the males but did not exhibit depressive symptoms, indicat-
ing burden was not a risk factor for depression for women. 

It is suggested that the burden women experience is not 
correlated with the caregiving situation, but instead reflects 
gender differences in nurturing roles seen within the general 
population (Gallicchio et al, 2002; Hooker, Manoogian-
O’Dell, Monahan, Frazier & Shifren, 2000) and within the 
age cohort (Moritz et al., 1989). Observed gender differ-
ences may be attributed to the gender-role socialization and 
social roles that women and men each assume (Miller & 
Cafasso, 1992; Collins & Jones, 1997). Women have been 
found to experience a greater burden because of their sense 
of responsibility to provide good care. They also tend to 
feel more comfortable in expressing their feelings and re-
porting their depression and burdensome feelings (Miller & 
Cafasso, 1992). It is possible that female caregivers are 
affected by different dynamics and therefore experience 
different consequences than their husbands (Tower et al., 
1997). 

Miller and Cafasso (1992) initiated the first analysis of 
gender differences in caregiving, and their findings support 
the notion of gender differences in the larger population 
rather than in the caregiving sample. The authors aimed to 
provide a foundation of the implications of gender differ-
ences in caregiving, however they did not specifically 
measure depression. Within the parameters of their analy-
sis, they found women were more likely to report caregiver 
burden, but could not specifically explain how this burden 
was expressed. These results supported elements of a hy-
pothesis based on both gender-role and social role socializa-
tion. Even though there was an effect for gender, this was 
small, and did not specifically explain which aspects of 
gender socialization contributed to the overall caregiving 
stress effect in women.  

 
Summary of Major Findings 

 
Given the narrow field of empirical and practical stud-

ies in the literature, the evidence linking psychiatric health 
effects and caregiving is robust, with virtually all studies 
reporting elevated levels of distress and depressive symp-
toms among caregivers (Schulz et al., 1995). Although the 
literature clearly demonstrates a link between the burden 
and psychological distress of caregiving, the underlying 
cause of this distress may relate to a number of different 
factors. 

In terms of primary stressors within caregiver relation-
ships, the level of impairment in the patient and the caregiv-
ing situation impacted the level of caregiver depression.  
The evidence of problem behaviors in a patient (which goes 
hand in hand with cognitive impairment) was implicated as 
leading to greater depressive symptomotology in caregiv-
ers. In addition, living with a cognitively impaired elder 
also predicted negative effects for the caregiver. The level 



HIRSHSON 
 

22 

of impairment was found to be associated with depressive 
symptoms in males as their wives’ cognitive impairment 
decreased, but this was only found for the male caregivers. 
Female caregivers did not exhibit more depressive symp-
toms when caring for a cognitively impaired husband. 

In terms of secondary stressors, having a social net-
work was found to be protective for both male and female 
caregivers. However, the level of closeness in the spousal 
relationship before the onset of illness was protective for 
females, but a risk factor for males. The literature suggests 
that while female caregivers may exhibit psychiatric mor-
bidity, they do not exhibit more depressive symptoms than 
male caregivers. This suggests that other differences ex-
perienced by male and female caregivers may be more re-
lated to overall social role differences that exist between the 
sexes in general.   

 
Limitations of Current Research and Future Directions 

 
Several limitations of the literature emerged from this 

review. In terms of research design, caregivers were often 
recruited from support groups, educational classes, or other 
support services. Using these samples may over represent 
the negative effects of caregiving. Furthermore, most stud-
ies used relatively small sample sizes and did not control 
for other factors known to influence mental health out-
comes, such as level of involvement in the caregiving role 
and sociodemographics (Ory et al., 1999).  The lack of con-
trol groups and the overall predominance of women care-
givers may point to women being more negatively affected, 
but this may not be an accurate representation. There is also 
a lack of valid and reliable measures in caregiving research. 
The Zarit Burden Interview (Zarit et al., 1980) is heavily 
relied on for research on caregivers, yet it may not clearly 
delineate the degree of encumbrance the patient causes or 
the ways in which patients burden caregivers. To further 
understand other factors possibly implicated, a measure 
needs to be able to capture the entire clinical picture.  

In addition, baseline levels of depression should be as-
sessed, requiring prospective research designs. Including a 
measure that looks retrospectively at life prior to the onset 
of the illness would possibly control for the perceived gen-
der role-socialization difference. Moreover, research in this 
field would benefit from using a different measure that 
evaluated the patient-caregiver relationship, as well as the 
quality of other relationships between patients and family 
members prior to the onset of the patient’s dementia. 

As stated previously, major limitation of research on 
caregivers surrounds conclusions about gender differences. 
Women are historically over-represented in caregiving re-
search and account for almost three-quarters of the caregiv-
ing population. Further studies need to take into account the 
higher levels of emotional stress found in women before 
considering the caregiving situation. The meta-analyses 
reviewed clearly indicated that women tend to report higher 
levels of emotional distress in the life course—without the 

caregiving aspect being considered (Miller & Cafasso, 
1992).  

Examining differences within caregiving in terms of 
both impact and burden is important to the field for both 
needs assessment and intervention purposes. The data gath-
ered from this research can be used for informing mental 
health professionals and primary care physicians responsi-
ble for treating this population. 

 
Conclusion 

 
Further research on caregivers of demented spouses is 

imperative. Future directions should include better recruit-
ment, more stringent study design and thorough, well vali-
dated measures. Gender, interpersonal relationships, and 
characteristics of the patient and the patient’s experience 
have been examined in this review; future research should 
continue to focus on these factors, all important aspects of 
the caregiving stress model, and work to clarify how each 
affects caregiving outcomes. 

 
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