Anxiety, Depression, and Spirituality Among Caregivers of Patients With Alzheimer Disease


1 Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

2 Department of Psychiatry, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

3 Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

4 Social Determinants of Health Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

5 Center for Research on Ethnicity, Culture, and Health (CRECH), University of Michigan School of Public Health, Ann Arbor, USA

6 Department of Psychiatry, School of Public Health, University of Michigan, Ann Arbor, USA


Introduction: The nature of the Alzheimer’s disease gradually makes patients dependent to persistent care. This may have a large negative effect on the caregivers’ quality of life and predisposes them to psychological distress. Spirituality, however, may act as a buffer and enhance their adaptability with stressful conditions. This study aimed to evaluate the association between spirituality and symptoms of anxiety and depression in a sample of caregivers of patients with Alzheimer’s disease.
Methods: In this cross-sectional study, 209 outpatients with moderate Alzheimer’s disease (using DSM-IV criteria and MMSE test) and their caregivers were selected. Patients’ and caregivers’ demographic data were recorded. The Spiritual Intelligence Questionnaire and Hospital Anxiety-Depression Scale were completed by caregivers.
Results: Spirituality was negatively correlated with depressive symptoms. Spirituality, however, had a positive but non-significant correlation with anxiety symptoms.
Conclusion: Although symptoms of anxiety and depression are highly prevalent in Alzheimer caregivers, only depressive symptoms are directly linked to spirituality. Spiritually-based approach may be a component of therapeutic interventions, in order to enhance caregivers’ adaptability.


1. Lopes MA, Hototian SR, Bustamante SE, Azevedo D, Tatsch M, Bazzarella MC, et al. Prevalence of cognitive and functional impairment in a community sample in Ribeirao Preto, Brazil. Int J Geriatr Psychiatry. 2007;22(8):770-6.
2. Zuidema SU, de Jonghe JF, Verhey FR, Koopmans RT. Neuropsychiatric symptoms in nursing home patients: factor structure invariance of the Dutch nursing home version of the neuropsychiatric inventory in different stages of dementia. Dement Geriatr Cognit Disord. 2007;24(3):169-76.
3. Amieva H, Rullier L, Bouisson J, Dartigues JF, Dubois O, Salamon R. [Needs and expectations of Alzheimer's disease family caregivers]. Rev Epidemiol Sante Publique.. 2012;60(3):231-8.
4. Gonzalez-Salvador MT, Arango C, Lyketsos CG, Barba AC. The stress and psychological morbidity of the Alzheimer patient caregiver. Int J Geriatr Psychiatry. 1999;14(9):701-10.
5. Zucchella C, Bartolo M, Pasotti C, Chiapella L, Sinforiani E. Caregiver burden and coping in early-stage Alzheimer disease. Alzheimer Dis Assoc Disord. 2012;26(1):55-60.
6. Mausbach BT, Chattillion EA, Roepke SK, Patterson TL, Grant I. A comparison of psychosocial outcomes in elderly Alzheimer caregivers and noncaregivers. Am J Geriatr Psychiatry. 2013;21(1):5-13.
7. Abdollahzadeh H BpM, Bouj Mehrani S, Lotfi M. Spritual intelligence: Concepts, Assessment and Applications. Tehran: Psychometric Publications; 2009. Persian
8. Zohar D MI. Spiritual Intelligence: The Ultimate Intelligence. New York: Bloomsbury Publishing PLC; 2001.
9. George LK LD, Koeing, Mccullough ME Spirituality and health: What we know, what we need to know. J Soc Clin Psychol. 2000;19(1):102-16.
10. Allen RS, Harris GM, Crowther MR, Oliver JS, Cavanaugh R, Phillips LL. Does religiousness and spirituality moderate the relations between physical and mental health among aging prisoners? Int J Geriatr Psychiatry. 2013;28(7):710-7.
11. Krumrei EJ, Pirutinsky S, Rosmarin DH. Jewish spirituality, depression, and health: an empirical test of a conceptual framework. Int J Behav Med. 2013;20(3):327-36.
12. Abedei F. The relation between spiritual intelligence and personality characteristics in individual between 19-50 years old in Sari. Behshahr: Payam Noor University; 2009. Persian
13. Shabani J, Hassan SA, Ahmad A, Baba M. Moderating influence of gender on the link of spiritual and emotional intelligences with mental health among adolescents. Life Sci J. 2011;8(1):106-12.
14. Gupta, G. Spiritual intelligence and emotional intelligence in relation to self-efficacy and self-regulation among college students. Int J Social Sci Interdisciplinary Res. 2012;1(2):60-9.
15. Yaghoobi A. The study of relation between spiritual intelligence and rate of happiness in booali university students. J Res Edu System. 2010;4(9):85-95.
16. Bolghan-Abadi M, Ghofrani F, Abde-Khodaei MS. Study of the Spiritual Intelligence Role in Predicting University Students’ Quality of Life. J Relig Health. 2014;53(1):79-85.
17. Yang KP. The spiritual intelligence of nurses in Taiwan. J Nurs Res. 2006;14(1):24-35.
18. Spurlock WR. Spiritual well-being and caregiver burden in Alzheimer's caregivers. Geriatr Nurs. 2005;26(3):154-61. 19. Kaye J, Robinson KM. Spirituality among caregivers. Image J Nurs Sch. 1994;26(3):218-21.
20. Wanchae P. Spirituality, depression and caregiver burden among family caregivers of Alzheimer's disease patients. California: California State University 2006.
21. Adamson E. Caring behaviour of nurses in Malaysia is influenced by spiritual and emotional intelligence, psychological ownership and burnout. Evid Based Nurs. 2014;17(4):121.
22. Kaur D, Sambasivan M, Kumar N. Effect of spiritual intelligence, emotional intelligence, psychological ownership and burnout on caring behaviour of nurses: a cross-sectional study. J Clin Nurs. 2013;22(21-22):3192-202.
23. Foroughan m, Jafari Z, Shiri BP, Ghaem Magham Faraahani Z, Rahgozar M. Validation of mini-mental state examination (MMSE) in the elderly population of Tehran. Adv Cogn Sci. 2008; 38, 29-37
24. Kaviani H, Seyfourian H, Sharifi V, Ebrahimkhani N. Reliability and validity of Anxiety and Depression Hospital Scales (HADS): Iranian patients with anxiety and depression disorders. TUMJ. 2009;67(5):379-85.Persian
25. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361-70.
26. Sohrabi F, Naseri E. A study of the conception and components of spiritual of intelligence and developing and instrument to assess it. Res Psychological Health. 2009;2(4):69-77.Persian
27. King DB, DeCicco TL. A viable model and self-report measure of spiritual intelligence. International Journal of Transpersonal Studies. 2009; 28(1):68-85.
28. Gallagher D, Rose J, Rivera P, Lovett S, Thompson LW. Prevalence of depression in family caregivers. The Gerontologist. 1989;29(4):449-56.
29. Mahoney R, Regan C, Katona C, Livingston G. Anxiety and depression in family caregivers of people with Alzheimer disease: the LASER-AD study. Am J Geriatr Psychiatry. 2005;13(9):795-801.
30. Nutt DJ. Depression, anxiety and the mixed conditions. New York: Wiley; 1997.
31. Kaviani H, Ghasemzadeh H. The Comorbidity Of Depression And Anxiety In A Sample of Iranian Patients. TUMJ. 2003;61(3):171-7.Persian
32. Maselko J, Gilman SE, Buka S. Religious service attendance and spiritual well-being are differentially associated with risk of major depression. Psychol Med. . 2009;39(6):1009-17.
33. Park J, Roh S. Daily spiritual experiences, social support, and depression among elderly Korean immigrants. Aging Ment Health. 2013;17(1):102-8.
34. Bekelman DB, Dy SM, Becker DM, Wittstein IS, Hendricks DE, Yamashita TE, et al. Spiritual well-being and depression in patients with heart failure. J General Internal Med. 2007;22(4):470-7.
35. Boscaglia N, Clarke DM, Jobling TW, Quinn MA. The contribution of spirituality and spiritual coping to anxiety and depression in women with a recent diagnosis of gynecological cancer. Int J Gynecol Cancer. 2005;15(5):755-61.
36. Greenstreet W. From spirituality to coping strategy: making sense of chronic illness. Br J Nurs. 2006;15(17):938-42.
37. Post SG, Puchalski CM, Larson DB. Physicians and patient spirituality: professional boundaries, competency, and ethics. Ann Intern Med. 2000;132(7):578-83.
38. Cooper C, Katona C, Orrell M, Livingston G. Coping strategies and anxiety in caregivers of people with Alzheimer's disease: the LASER-AD study. J Affect Disord. 2006;90(1):15-20.
39. Min J-A, Jung Y-E, Kim D-J, Yim H-W, Kim J-J, Kim T-S, et al. Characteristics associated with low resilience in patients with depression and/or anxiety disorders. Qual Life Res.2013;22(2):231-41.
40. Koenig HG. Research on religion, spirituality, and mental health: a review. Can J Psychiatry. 2009;54(5):283-91.
41. Yiengprugsawan V, Seubsman SA, Lim L, Sleigh A, the Thai Cohort Study T. Social Capital, Trust, Economic Stress and Religion in a Cohort of 87,134 Thai Adults. Warasan Prachakon Lae Sangkhom. 2011;19(2):183-96.
42. Park NS, Lee BS, Sun F, Klemmack DL, Roff LL, Koenig HG. Typologies of religiousness/spirituality: implications for health and well-being. J Relig Health. 2013;52(3):828-39.
43. Boelens PA, Reeves RR, Replogle WH, Koenig HG. The effect of prayer on depression and anxiety: maintenance of positive influence one year after prayer intervention. Int J Psychiatry Med. 2012;43(1):85-98.
44. Bussing A, Hedtstuck A, Khalsa SB, Ostermann T, Heusser P. Development of Specific Aspects of Spirituality during a 6-Month
Intensive Yoga Practice. Evid Based Complement Alternat Med. 2012;2012:981523.
45. Glueckauf RL, Davis WS, Allen K, Chipi P, Schettini G, Tegen L, et al. Integrative cognitive-behavioral and spiritual counseling for rural dementia caregivers with depression. Rehabil Psychol. 2009;54(4):449-61.
46. Cotton S, Zebracki K, Rosenthal SL, Tsevat J, Drotar D. Religion/spirituality and adolescent health outcomes: a review. The J Adolesc Health. 2006;38(4):472-80.
47. D'Souza R. The importance of spirituality in medicine and its application to clinical practice. Med J Aust. 2007;186(10 Suppl):S57-9.