gilliam and steffen (2006)-1

Aging & Mental Health, March 2006; 10(2): 7986

ORIGINAL ARTICLE

The relationship between caregiving self-efficacy and depressivesymptoms in dementia family caregivers

C. M. GILLIAM & A. M. STEFFEN

Department of Psychology, University of Missouri, St. Louis, Missouri, USA

(Received 12 November 2004; accepted 4 April 2005)

AbstractThe present study was intended to replicate the findings of Steffen et al. (2002) of a negative relationship betweencaregiving self-efficacy and depressive symptoms among family dementia caregivers. Female family caregivers (N 74)of community-dwelling individuals diagnosed with dementia completed a telephone interview and self-report assessmentpacket that included measures of caregiving self-efficacy and depressive symptoms. There was a direct negative relationshipbetween caregiving self-efficacy and depressive symptoms after controlling for objective stressors. There was no support,however, for the hypothesis that caregiving self-efficacy would operate as a moderator, such that the relationship betweenobjective stressors (cognitive impairment and behavior problems) and caregivers depressive symptoms would be strongestfor caregivers reporting lower levels of self-efficacy. The results of this study suggest that caregiving self-efficacy has a strong,direct relationship with depressed symptoms for dementia family caregivers. Longitudinal research is needed to determineif it is an appropriate focus of future intervention research.

Introduction

Caregivers of family members diagnosed withdementia are engaged in a challenging and importantrole that often consumes their lives. The demandsand emotional strains associated with dementiacaregiving leave caregivers vulnerable to psycholog-ical and health consequences, most frequently,depression. The relationship between depressivesymptoms and caregiving has been found in virtuallyall studies of dementia caregivers (Schulz et al.,1995). Not all, however, experience similar negativeeffects of caregiving. Some individuals experiencesignificant distress; others are able to managethe process of caregiving without experiencingpsychosocial impairment (Aneshensel et al., 1995).

In order to develop effective interventions, it isimportant to identify and understand the factorsthat protect some caregivers from negative conse-quences frequently associated with caregiving.Although objective stressors have been proposed asleading to depressive symptoms among caregivers,the results are ambiguous. Some studies finda direct relationship between depressive symptomsand the objective stressors of caregiving, such ascognitive impairment, behavioral problems, andactivities of daily living (ADL) deficiencies of thepatient (Alspaugh et al., 1999; Donaldson et al.,1998; Nagaratnam et al., 1998; Teri, 1997).

Others have not, suggesting that other variablesbesides objective stressors are responsible for theheterogeneity in depression among family dementiacaregivers (Boss et al., 1990; Gaugler et al., 2000;Li et al., 1999; Schulz et al., 1995). These conflict-ing results imply that primary objective stressors,the actual demands of caregiving, may not bedirectly related to depressive symptoms. Instead,other factors such as a caregivers perception of thecaregiving situation or his/her ability to managecaregiving-related demands may be more stronglyrelated.

One such variable proposed as playing an impor-tant role in the relationship between caregivingand depressive symptoms is self-efficacy (Bandura,1977; Fortinsky et al., 2002; Gignac & Gottlieb,1996; Zeiss et al., 1999). Self-efficacy (also calledperceived self-efficacy) is an individuals assessmentof his or her ability to successfully master a specifictask (Bandura, 1997). These efficacy beliefs arean individuals estimates of her or his own abilityto mobilize the motivation, cognitive resources, andcourses of action needed to meet given situationaldemands (Bandura & Wood, 1989, p. 408). Self-efficacy is by definition concerned with the indivi-duals assessment of ability to perform a specifictask, and differs from a more general assessment

Correspondence: Christian M. Gilliam, Psychology Department, 325 Stadler Hall, One University Blvd., St. Louis,Missouri 63121, USA. Tel: 1 (314) 516 5391. Fax: 1 (314) 516 5392. E-mail: [email protected] 1360-7863 print/ISSN 1364-6915 online 2006 Taylor & FrancisDOI: 10.1080/13607860500310658

of abilities, such as self-mastery or a global evalua-tion of the self encompassed in the concept of self-esteem. One can have high self-efficacy in a certaindomain but not another. Unlike self-esteem andself-mastery, which are conceived as relatively stableconstructs, self-efficacy often changes within thesame individual over time and in response to specificexperiences (Bandura, 1997).

Those with a high sense of caregiving efficacy maybe protected from the negative consequencesof this role by focusing on what they are capableof accomplishing, rather than on their failures.Rather than viewing the demands of caregivingas tasks to be avoided, those with a high senseof caregiving self-efficacy may view them as chal-lenges to be mastered. In short, a resilient senseof self-efficacy enables people to endure hardshipsand persevere against great odds (Bandura, 1997,p. 22) that are associated with caregiving.Individuals with a low sense of caregiving self-efficacy, on the other hand, are more vulnerable tothe stressors of caregiving and the potential negativeconsequences, especially depression. In the faceof challenges, which undoubtedly occur frequentlyin dementia caregiving, these individuals are morelikely to focus on past failures and doubt their abilityto effectively respond to the demands of caregiving.

Of the studies examining the relationship betweenself-efficacy and depression in non-caregivingsamples, some suggest a direct causal relationshipbetween self-efficacy and depressive symptoms,whereas others suggest a buffering, or moderatingeffect of self-efficacy on depression. Stanley andMaddux (1986), for example, examined thedirect causal relationship between self-efficacy forinterpersonal skills and depressed mood. Usingan experimental manipulation of participantsself-efficacy regarding interpersonal skills, theinvestigators found that those with an induced lowself-efficacy expectancies reported greater depressedmood than those with induced high self-efficacyexpectancies. Induction of depressed or elatedmood, however, had no corresponding effect onthe participants self-efficacy regarding social inter-actions, suggesting a one-way causal relationshipbetween a specific type of self-efficacy and depressedmood. In a longitudinal study of cardiac rehabilita-tion patients, early-treatment changes in exerciseself-efficacy predicted late-treatment improvementsin activity level, depressive symptoms, and patient-staff working alliance. These positive outcomes,however, did not predict changes in exercise self-efficacy. Results from this longitudinal interventionstudy further suggest a one-way causal relationshipbetween certain types of self-efficacy and depressivesymptoms (Evon & Burns, 2004).

Among older adults, self-efficacy in specificareas has also been found to play a moderatingrole between key domains of an older adults life(e.g., physical health, financial situation, relationship

with adult children, and social support from friends)and depressive symptoms (Chou & Chi, 2001).Moderators help clarify why people react differentlyto similar situations. In the case of caregivers,for example, a moderator can identify a cognitivecharacteristic that may influence the relationshipbetween stressors and depression. Two dementiacaregivers whose impaired relatives have the samelevel of cognitive impairment and behavioral prob-lems, for example, may not experience the sameamount of depressive symptoms. The caregiverwith high self-efficacy and high stressors may onlyexperience a low level of depressive symptoms whilethe caregiver with low self-efficacy and high stressorsmay experience a higher level of depressivesymptoms.

Self-efficacy has been applied to explain thediverse reactions of individuals to stressful lifeexperiences, and has more recently been appliedto the stressor of caregiving for a family member withdementia. To date, the few studies in this area havefound a negative relationship between self-efficacyand depression among dementia caregivers (Gignac& Gottlieb, 1996; Steffen et al., 2002; Zeiss et al.,1999). Although these investigators have examineddifferent types of self-efficacies, such as copingself-efficacy, caregiving self-efficacy, and problem-solving self-efficacy, they have all found that thosewith higher self-efficacy were less likely to reportdepressive symptoms.

The aim of this study was to clarify the roleof caregiving self-efficacy in the relationship betweenobjective primary stressors and depressive symp-toms. Specifically, we examined whether self-efficacyfor responding to problematic patient behaviorsmoderates the relationship between the objectivestressors of caregiving (cognitive impairment andbehavioral problems) and caregiver depressivesymptoms.

Method

Participants

The data for this paper were collected as part ofan intervention study for female dementia caregiverswith depressive symptoms. A variety of strategieswere used to recruit participants from nine centralUS states (Illinois, Indiana, Iowa, Kansas, Michigan,Minnesota, Missouri, Nebraska, and Wisconsin),including calling agency staff at all chapters of theAlzheimers Association and Area Agency on Aging(AAA), and providing brochures and articles aboutthe program. Caregivers who called in for moreinformation about the program received a telephonescreening interview to determine interest and eligi-bility. Criteria for inclusion in the study includedbeing female aged 3080, and a primary caregiverwho lives with a family member with a physicianconfirmed diagnosis of dementia. In order to be

80 C. M. Gilliam & A. M. Steffen

included in the study, the caregiver needed to reportdepressive symptoms as indicated by a score of threeor higher (out of a possible score of 10) on theBoston Short Form of the Center for EpidemiologicStudies of Depression Scale (CES-D) (Kohut et al.,1993), and at least moderate distress followingat least two weekly-occurring behavioral problemsof the patient, as measured by the Revised Memoryand Behavior Problems Checklist (Teri et al., 1992).Caregivers were excluded from the study if theyexhibited disabling hearing impairment as measuredby the Hearing Handicap Inventory for the Elderly(Ventry & Winstein, 1982), disabling visual impair-ment as measured by the Low Vision Quality of LifeScale (Wolffsohn & Cochrane, 2000), or significantcognitive impairment, as measured by the tele-phone version of the Short Portable Mental StatusQuestionnaire (Roccaforte et al., 1994). Otherexclusionary criteria included significant suicidalideation, current alcohol or drug abuse, or nothaving access to a telephone or VCR.

As shown in Table I, the majority of caregiverswere Caucasian (79.7%), with an average age of59 years. Most caregivers were married (71%), withapproximately half of caregivers (52.2%) caring fortheir husband, and the other half caring for a parent(38% mother; 6% father). Less than 5% of care-givers were caring for other family members (grand-parent, aunt or mother-in-law). Less than half(36.5%) of the caregivers worked either full orpart-time outside of the home, and approximatelyhalf reported an income of at least $40,000 (54.1%).Only a small number of caregivers reported havingsignificant financial difficulty (9.5%). The caregiverswere well educated, with the majority reporting

completion of some type of post-high schooleducation.

The average participant reported being a caregiverfor approximately three years. Although an attemptwas made to assess the amount of time the caregiversspent providing direct assistance to their relative,caregivers often reported spending 24 hours per daycaregiving; as such, this variable was not includedas it did not appear to accurately assess the actualamount of time caregivers spent providing assis-tance or supervision to their relatives on a dailybasis. Approximately 50% of the caregivers reportedreceiving one type of formal services to assist caringfor their family member, such as a homemaker, ahome health aid, a visiting nurse, delivery of cookedmeals, provision of transportation, or having theirfamily member attend a day care. Approximately24% of the caregivers reported that they receivednone of the formal services described above, andapproximately 26% of the caregivers reportedreceiving two or more of the services describedabove. The most frequently reported formal supportwas senior day care attendance by the familymember (38%).

As shown in Table II, the average dementiapatient was a Caucasian (78%) male (58%) in hismid seventies. The majority of the patients weremarried, with the more than half having at leasta high school diploma (66.5%). The average patientneeded assistance in two areas among the activitiesof daily living, such as bathing or toileting, and themajority of the patients were described by theircaregivers as being in good physical health.

Measures

Caregiving self-efficacy. Self-efficacy was measuredusing the Revised Scale for Caregiving Self-Efficacy(Steffen et al., 2002). The scale consists of 15 items;

Table I. Demographic characteristics of participants (N 74).

Caregiver characteristics Means/percentages n Range

Age 58.9 years(10.5)

74 (33.185.2years)

EducationSome high school 5.4% 4High school diploma 20.3% 15Post high school training 88.2% 55

Ethnic backgroundCaucasian 79.7% 59African-American 18.9% 14Other 1.4% 1

Marital statusMarried 67.6% 50Not married/widowed 32.4% 24

Employment statusFull-time 24.3% 18Part-time 12.2% 9Not employed 63.5% 47

IncomeLess than $20,000 16.7% 12Less than $40,000 29.2% 21Above $40,000 54.1% 39

Length of caregiving 2.94 years 0.069.96years

Table II. Patient characteristics (N 74).

Caregiver characteristics Means/percentages n Range

Age 75.4 years (9.1) 74 (54.892.5years)

GenderMale 58.2% 39Female 41.8% 28

Relation to caregiverMother 37.3% 25Father 6% 4Husband 52.2% 35Other relative 4.5% 3

Type of dementing illnessAlzheimers disease 60.8% 45Undecided dementia 21.6% 16Vascular dementia 8.1% 6Mixed dementia 5.4% 4Dementia secondary to

Parkinsons disease1.4% 1

Other type of dementia 2.7% 2ADL impairment 2.01 (1.75) 74 06

Caregiving self-efficacy and depressive symptoms 81

caregivers were asked to rate their level of confidence(from 0100%) that they could perform each activityif they gave their best effort. For example, caregiverswere asked to rate their confidence as 0% if theybelieve they could not perform an activity at all, 20%if they believed it was unlikely but not impossibleto perform the activity, 5060% if they weremoderately certain they could perform the activity,and 100% if they were certain they could performthe activity with their best effort. The measurebegins with a detailed explanation and opportunityto practice reporting confidence levels with non-caregiving related tasks. Each item on the scale asksthe caregiver to assess their confidence level forbeing able to perform a behaviorally specific task.The scale is divided into three subscales assessingthree domains of caregiving self-efficacy. (1) Self-care and obtaining respite (5 items): this scalemeasures caregivers self-efficacy regarding theability to ask for assistance (e.g., How confidentare you that you can ask a friend/family member tostay with your family member for a day when youneed to see the doctor?). (2) Responding to disrup-tive patient behaviors (8 items): this scale assessescaregivers self-efficacy regarding the ability torespond to the patients disruptive behaviors effec-tively. (e.g., When your family member asks youfour times in the first hour after lunch when lunch is,how confident are you that you can answer him/herwithout raising your voice?). (3) Controlling upset-ting thoughts activated by caregiving activities: thisscale measures caregivers self-efficacy regardingcontrolling negative or upsetting thoughts concernedwith caregiving (5 items). (e.g., How confident areyou that you can control worrying about futureproblems that may come up with your familymember?). Due to our specific interest in caregiversresponses to difficult behaviors of the patient, onlythe scale for responding to disruptive patient behav-iors (5 items) was examined in relation to depressivesymptoms for the present study. This scale hasdemonstrated good reliability and validity and highinternal consistency in past studies (Cronbachsalpha 0.82) with two-week test retest reliabilitymoderate and in the acceptable range (r0.70;Steffen et al., 2002). In the present study, thescale was normally distributed with high internalconsistency (Cronbachs alpha0.88).

Depressive symptoms. Depressive symptoms weremeasured by the Beck Depression Inventory-Second Edition (BDI-II) Long Form (Beck, Steer,& Brown, 1996). The BDI-II consists of 21 itemsdesigned to measure the degree of depressive symp-toms in adults and adolescents age 13 and older.Participants were asked to pick the statement thatbest described the way that they had been feeling inthe last two weeks, including the day of the interview(Beck, Steer, & Brown, 1996). The BDI-II has goodreliability and validity. It has strong internal

consistency, with a coefficient alpha of 0.92, andgood one week test-retest reliability (r 0.93,p< 0.001). In the present study, the items werenormally distributed and demonstrated high internalconsistency (Cronbachs alpha 0.89).

Behavior problems. The Revised Memory andBehavior Problems Checklist (RMBPC; Rothet al., 2003; Teri et al., 1992) was used to measurecaregivers report of the dementia patients observ-able behavior problems, such as memory problems,depressive symptoms, and disruptive behaviors.The checklist consists of 25 items, which representpossible problems that the patient may be exhibiting.The caregiver was asked whether a particularbehavior or memory problem had occurred in thepast week (Roth et al., 2002), with a score createdfor the total number of behavior problems endorsedby the caregiver. The checklist has good reliabilityand convergent and discriminant validity. For exam-ple, endorsement of memory related problemscorrelated negatively with the Mini-Mental StatusExam and positively with the diagnosis of dementiaof the family member (r0.48/0.45, p< 0.001)(Teri et al., 1992). In the present study, the totalscore was normally distributed and had adequateinternal consistency (Cronbachs alpha 0.74).

Telephone measure of cognitive impairment. This scalemeasures the degree of cognitive impairment of thefamily member, such as memory loss, communica-tion deficits, and recognition failures, throughreports by the caregiver. Caregivers were asked torate how difficult it is for the relative to performeach of the seven items, on a scale from 0 (not atall difficult) to 5 (cant do at all) (Aneshensel et al.,1995). The scale has been found to adequatelyevaluate the level of cognitive impairment forbrief screening purposes. The scale correlateshighly (r0.65) with the Mini-Mental State Exam(Folstein et al., 1975). The scale demonstratedadequate internal consistency in the present study(Cronbachs alpha 0.82).

Descriptive information. A brief demographicquestionnaire assessed the caregiver and the familymembers ethnic background, educational level,income and financial status, marital status, age,and general health. The Index of Activities ofDaily Living (Katz et al., 1963) was also utilized toobtain descriptive information regarding the familymembers ability perform activities of daily livingwith or without assistance, such as bathing, toileting,and eating.

Procedure

Once a caregivers eligibility and interest in partic-ipating in the study were determined, a baselinetelephone interview was scheduled; consent forms


and response cards to assist with the telephoneinterview process were mailed to the caregiver.At the beginning of the baseline telephone call,informed consent was obtained. Following theinformed consent procedures, the measures usedin the present study were administered over thetelephone in the following order: The Index ofActivities of Daily Living (Katz et al., 1963), TheRevised Memory and Behavior Problems Checklist(Teri et al., 1992), The Telephone Measure ofCognitive Impairment (Aneshensel et al., 1995),The Beck Depression Inventory-Second Edition(Beck, Steer, & Brown, 1996), and The Self-Efficacy Scale for Responding to Disruptive PatientBehaviors (Steffen et al., 2002). These measureswere completed over the phone rather than mailedto the caregiver to increase the likelihood of thecaregiver responding and completing the measuresaccurately. Demographic data were collected ina questionnaire format that participants mailedback to the research office.

Results

Table III shows variable distributions and intercor-relation among study variables. On average, care-givers reported mild levels of depressive symptomson the BDI-II (M 15.8). The average confidencelevel for responding to various disruptive behaviorsamong caregivers was 67%. The level of depressivesymptoms reported among this studys participantsis comparable to those of other intervention studiesassessing depressive symptoms among caregiversof dementia patients. Two intervention studiesassessing depressive symptoms with the BDI-IIamong dementia family caregivers reported anaverage BDI-II score of 13 (Coon et al., 2003) and19.3 (Gallagher-Thompson & Steffen, 1994).Participants also displayed a moderate level of

confidence in responding to various behaviorproblems on the RMBPC.

The average dementia patient in the study showedapproximately 1112 different types of behavioralproblems within a week of the interview, and hadquite a bit of difficulty performing various cognitivetasks. Pearson correlations were conducted toexamine any problems with multicollinearity; asillustrated in Table III, there were no concernswith multicollinearity in the data.

To test the studys hypotheses, two hierarchicalregression analyses with scores on the BDI-II as thedependent variable were conducted. Scores on theTelephone Measure of Cognitive Impairment andthe Revised Memory and Behavior ProblemsChecklist were entered into block 1. In block 2,self-efficacy for responding to disruptive behaviorswas entered. The product of self-efficacy andbehavior problems (Regression #1) or the productof self-efficacy and cognitive impairment (Regression#2) was entered into block three.

Contrary to our hypothesis, self-efficacy forresponding to problematic patient behaviors didnot act as a moderator between patient cognitiveimpairment or behavioral problems and caregiverdepressive symptoms. As illustrated in Table IV,neither interaction significantly improved the abilityof the model to predict scores on the BDI-II.The interaction between self-efficacy and behaviorproblems or the interaction between self-efficacyand cognitive impairment accounted for less than1% of the variance in scores on the BDI-II. Further,the relationship between objective stressors anddepressive symptoms was not significant, accountingfor less than 2% of the variance in scores on theBDI-II. Neither behavior problems (beta 0.54,p 0.65) nor cognitive impairment (beta 0.12,p 0.34) significantly predicted depressive symp-toms of the caregivers. In comparison, self-efficacy

Table III. Pearson correlation of cognitive impairment and behavior problems (N 74).

Variable Mean (SD) Range 1 2 3 4 5

1. Beck Depression Inventory 15.76 (3.33) 033 2. Cognitive Impairment 2.58 (1.07) 0.434.71 0.11 3. Behavior Problems 11.55 (3.33) 420 0.05 0.02 4. Self-Efficacy 67.23 (19.82) 1598.75 0.40* 0.11 0.13 5. ADLs 2.01 (1.75) 06 0.05 0.44* 0.04 0.00

*Correlations significant at the 0.01 level.

Table IV. Hierarchical multiple regressions predicting scores on BDI-II (N 72).

Block R2 R2 Change Significance of change

(1) Behavior problems and cognitive impairment 0.016 0.016 0.571(2) Caregiving self-efficacy 0.196 0.180 0.000(3) Product of behavior problems and self-efficacy 0.198 0.002 0.710(3) Product of cognitive impairment and self-efficacy 0.199 0.003 0.597


accounted for approximately 18% of the varianceafter controlling for objective stressors, and signifi-cantly predicted scores on the BDI-II. Ashypothesized, self-efficacy had a significant nega-tive relationship with depressive symptoms(beta0.43, p< 0.001). The Pearson r for adirect correlation between self-efficacy and depres-sion (r0.40) and the partial correlation aftercontrolling for behavioral problems are nearlyidentical (r0.41), providing further evidencethat the relationship between self-efficacy anddepression was not affected by patient behavioralproblems.

As discussed in the Measurement section of thispaper, the items used to measure caregiving self-efficacy in the present study are behaviorally specificdescriptions of common disruptive behaviors bydementia patients, and are different in contentto the BDI-II items. Despite the apparent differencein item content between the BDI-II and the self-efficacy items, the significant correlation betweenthe BDI-II and caregiving self-efficacy suggests thatthere may be a potential confound between care-givers self-efficacy for responding to disruptivebehaviors and depressive symptoms. In an attemptto tease apart a potential confound between self-efficacy and depressive symptoms in these care-givers, hierarchical regression analyses to test themain hypotheses were also conducted with a reviseddependent variable that excluded items assessingsomatic or lethargic symptoms on the BDI-II (item15: loss of energy; item 16: changes in sleepingpatterns; item 20: fatigue/tiredness). As shown inTable V, removal of these three BDI-II items didnot result in any significant changes to the analyses.No moderating relationship was found between therecalculated BDI-II scores and self-efficacy aftercontrolling for objective stressors.

Discussion

The present study hypothesized that caregiving self-efficacy functions as a moderator between objectivestressors and caregivers depressive symptoms. Therelationship between self-efficacy and depressivesymptoms appears to be a direct relationship,and not a moderating relationship as hypothesized.Whereas objective stressors did not demonstratea significant impact on depressive symptoms,

self-efficacy maintained a significant negativerelationship with depressive symptoms, even aftercontrolling for objective stressors.

The significant relationship between caregivingself-efficacy and depressive symptoms found in thisstudy is consistent with both the literature onself-efficacy and depression in general, as well aswith the literature on self-efficacy and depressionspecific to dementia caregivers. Using a different,non-intervention sample of dementia caregivers,Palmer and Steffen (2004) also found a directnegative correlation (r0.38) between caregivingself-efficacy and depressive symptoms. Furthermore,in the sample, initially lower levels of caregivingself-efficacy predicted length of time to nursinghome placement over seven years, while controllingfor initial levels of depressive symptoms.

In addition to providing further evidence support-ing the relationship between caregiving self-efficacyand depressive symptoms, the results of this studyprovide further understanding of the relationshipbetween self-efficacy and caregiver depression.First, by controlling for the objective stressors ofcaregiving, the results demonstrate that self-efficacyhas a significant relationship with depressive symp-toms even after accounting for differences in theobjective stressors of caregiving. In other words,regardless of the level of cognitive impairment orbehavioral problems that the caregivers face,self-efficacy maintains a significant relationshipwith depressive symptoms. The results also suggestthat the caregivers self-efficacy is not simply deter-mined by the objective challenges of caregiving.The findings are consistent with Banduras (1977)self-efficacy theory.

There are at least three published studies exam-ining caregiving self-efficacy in relation to depressivesymptoms (Fortinsky, Kercher, & Burant, 2002;Steffen et al., 2002; Zeiss et al., 1999). Consideringthat self-efficacy is concerned with the caregiversperceived ability to execute a particular domainof tasks, and not a general sense of global mastery,and that self-efficacy can differ in level, generality,and strength, it is not surprising that there are avariety of ways of defining and measuring caregivingself-efficacy (Bandura, 1977). For example, Zeissand her colleagues (1999) examined caregiversself-efficacy for self-care and problem solving.Although they found a significant relationshipbetween depression and self-efficacy, Zeiss and

Table V. Hierarchical multiple regressions predicting scores on BDI-II with lethargy removed(N72).

Block R2 R2 Change Significance of change

(1) Behavior problems and cognitive impairment 0.015 0.015 0.597(2) Caregiving self-efficacy 0.181 0.166 0.000(3) Product of behavior problems and self-efficacy 0.183 0.003 0.644(3) Product of cognitive impairment and self-efficacy 0.183 0.003 0.644


her colleagues reported that their measure ofself-efficacy was not a strong predictor of caregiverdistress. In addition, their measurement of problem-solving self-efficacy was generalized, and did notfocus on specific situations or caregiving tasks.The self-efficacy scale used in this study is a revisionof the scale used by Zeiss et al. (1999) to improveupon the ceiling effects and include a broader rangeof items that assess the caregivers self-efficacyin responding to various behavioral problems(Steffen et al., 2002). The relationship foundbetween caregiving self-efficacy and depressionin this study was stronger than that found in thestudy by Steffen et al. (2002) (r0.31 andr0.34 in the study by Steffen et al., as comparedto r0.43 in this study). Given that the scale usedto measure caregiving self-efficacy in the two studieswas identical, the stronger relationship betweenself-efficacy for responding to disruptive patientbehaviors found in this study can be attributed todifferences in caregiver characteristics between thetwo studies. In order to be included into the study,the caregivers in this study were reporting distressregarding patient behavioral problems and somedepressive symptoms, as well as an interest inparticipating in a caregiver intervention program.The association between caregiving self-efficacy anddepressive symptoms, therefore, may be strongerwhen applied to caregivers who are at least mildlydepressed or distressed, and help-seeking.

A recent study by Fortinsky and his colleagues(2002) examined the relationship between symptommanagement self-efficacy and caregiver depression,and found very similar results to those of this study.Our research, however, unlike the study by Zeisset al., or by Fortinsky et al., which used a moreglobal measure of caregiving self-efficacy, specificallyexamined self-efficacy in regards to the ability torespond to common disruptive behaviors, such asrepeated questioning, or following the caregiver.The measurement of self-efficacy used in thisstudy assessed caregiving self-efficacy in responseto specific and diverse situations frequently encoun-tered by dementia caregivers. The intermediate levelof generality assessed in this measure yields a greaterpredictive power while still measuring the domainof the caregivers self-efficacy in responding todisruptive behaviors (Bandura, 1997).

Although the results of this study contributefurther to the understanding of self-efficacy anddepressive symptoms among dementia family care-givers, there are some limitations. First, due to thecorrelational design of this study, no conclusions canbe drawn regarding a causal relationship betweencaregiving self-efficacy and depressive symptoms.Present results suggest that caregiving self-efficacyand depressive symptoms have a significant associ-ation; however, such an association may simplyreflect a potential confound between self-efficacyand depressive symptoms. The current study cannot

answer the question of why caregiving self-efficacyand depressive symptoms are related. Futureresearch, particularly longitudinal and interventionresearch will help shed light on the relationshipbetween caregiving self-efficacy and depressivesymptoms.

Further, in addition to the general problem ofrelying solely on self-report measures, the measure-ment of behavioral problems may have includedmore memory or cognitive problems associated withdementia rather than the behavioral problems foundto be most distressing to caregivers, such as violentbehavior, or constant following of the caregiver.In addition, most of the caregivers in the study didnot report the more distressing behavioral problemsincluded in the measure. This may account for thenon-significant relationship found between behav-ioral problems and caregivers depressive symptoms.

An obvious limitation to the study is the partic-ipant characteristics. As in most caregiver studies,the study participants were self-selected into thestudy. The caregivers were all female, mostlyCaucasian, well educated, and mostly from a highsocioeconomic status. The results of this study,therefore, many not generalize to caregivers fromlower socioeconomic status, with lower education,caregivers uninterested or not capable of participat-ing in an intervention study, for caregivers of ethnicminority, or to male caregivers. In fact, there issome research to suggest that the consequences oflong-term caregiving differ for African-American andCaucasian caregivers, as well as for male and femalecaregivers (Roth, Haley, Owen, & Clay et al, 2001;Gallicchio, Siddiqi, Langenberg, & Baumgarten,2002). Caregivers financial status also undoubtedlyinfluences the nature of caregiving; those withfinancial resources can more easily acquire profes-sional assistance, such as a home health aid, orrespite. Adequate financial resources, therefore, mayease some of the stressors of caregiving.

Of particular interest within self-efficacy researchamong dementia caregivers is the relative importanceof different types of caregiving self-efficacy.Caregiving is a challenging role that demands thatcaregivers be able to respond to a variety of differentsituations and tasks. Caregivers must be able tocoordinate medical care, be responsible for thefinances, as well as assist the impaired relativein daily activities of living and keeping the homesafe, among many others. The different types ofself-efficacy measured within caregiving researchdemonstrate the diverse range of responsibilitiesfor caregivers (Steffen et al., 2002; Fortinsky,Kercher, & Burant, 2002; Zeiss et al., 1999;Gignac & Gottlieb, 1996). In fact, the measurementof caregiving self-efficacy used for this study, thecaregivers self-efficacy in responding to disruptivebehaviors, is only one of the three types of care-giving self-efficacy measured in the Scale forCaregiving Self-Efficacy (Steffen et al., 2002).


Although the caregivers self-efficacy for respondingto disruptive behaviors was chosen for this study, theother types of self-efficacy measured by the Scalefor Caregiving Self-Efficacy, self-efficacy for self-careand obtaining respite, and for controlling upsettingthoughts, may also prove to be informative inunderstanding caregivers depressive symptoms.Comparisons of different types of caregiving self-efficacy may shed further light on the relationshipbetween self-efficacy and caregiving.

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