Annals of Behavioral Medicine

, Volume 47, Issue 2, pp 198–207 | Cite as

Does Caregiving Cause Psychological Distress? The Case for Familial and Genetic Vulnerabilities in Female Twins

  • Peter P. Vitaliano
  • Eric Strachan
  • Elizabeth Dansie
  • Jack Goldberg
  • Dedra Buchwald
Original Article



Informal caregiving can be deleterious to mental health, but research results are inconsistent and may reflect an interaction between caregiving and vulnerability to stress.


We examined psychological distress among 1,228 female caregiving and non-caregiving twins. By examining monozygotic and dizygotic twin pairs discordant for caregiving, we assessed the extent to which distress is directly related to caregiving or confounded by common genes and environmental exposures.


Caregiving was associated with distress as measured by mental health functioning, anxiety, perceived stress, and depression. The overall association between caregiving and distress was confounded by common genes and environment for mental health functioning, anxiety, and depression. Common environment also confounded the association of caregiving and perceived stress.


Vulnerability to distress is a factor in predicting caregivers' psychosocial functioning. Additional research is needed to explicate the mechanisms by which common genes and environment increase the risk of distress among informal caregivers.


Twins Caregiving Psychological distress 



This research was supported by the National Institutes of Health grants RC2 HL103416 (D. Buchwald) and R01 AR051524 (N. Afari) and AG023629 (P. Vitaliano). We wish to thank the twins for taking part in the University of Washington Twin Registry and for their time and enthusiasm for this project.

Conflict of Interest

The authors have no conflict of interest to disclose.


  1. 1.
    National Alliance for Caregiving, AARP. Caregiving in the US. Washington, DC; 2009.Google Scholar
  2. 2.
    Rosalynn Carter Institute for Caregiving. Averting the caregiving crisis: Why we must act now. Americus, GA; 2010; 5-12.Google Scholar
  3. 3.
    National Alliance for Caregiving, AARP. Caregiving in the US. Washington, DC; 2004.Google Scholar
  4. 4.
    Marks NF, Lambert JD, Choi H. Transitions to caregiving, gender, and psychological well-being: A prospective US national study. J Marriage Fam. 2002; 64: 657-667.CrossRefGoogle Scholar
  5. 5.
    Pearlin LI, Semple S, Turner H. Stress of AIDS caregiving: A preliminary overview of the issues. Death Stud. 1988; 12: 5-6.CrossRefGoogle Scholar
  6. 6.
    Shahly V, Chatterji S, Gruber M, et al. Cross-national differences in the prevalence and correlates of burden among older family caregivers in the World Health Organization World Mental Health (WMH) Surveys. Psychol Med. 2012; 9: 1-15.Google Scholar
  7. 7.
    Pinquart M, Sorensen S. Differences between caregivers and non-caregivers in psychological health and physical health: A meta-analysis. Psychol Aging. 2003; 18: 250-267.PubMedCrossRefGoogle Scholar
  8. 8.
    Dyck DG, Short R, Vitaliano PP. Predictors of burden and infectious illness in schizophrenia caregivers. Psychosom Med. 1999; 61: 411-419.PubMedGoogle Scholar
  9. 9.
    Lutgendorf SK, De Geest K, Bender D, et al. Social influences on clinical outcomes of patients with ovarian cancer. J Clin Oncol. 2012; 30: 2885-2890.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Mosher CE, Danoff-Burg S. Psychosocial impact of parental cancer in adulthood: A conceptual and empirical review. Clin Psychol Rev. 2005; 25: 365-382.PubMedCrossRefGoogle Scholar
  11. 11.
    Molloy GJ, Johnston DW, Witham MD. Family caregiving and congestive heart failure. Review and analysis. Eur J Heart Fail. 2005; 7: 592-603.PubMedCrossRefGoogle Scholar
  12. 12.
    Schieve LA, Blumberg SJ, Rice C, Visser SN, Boyle C. The relationship between autism and parenting stress. Pediatrics. 2007; 119: 114-121.CrossRefGoogle Scholar
  13. 13.
    Whitlatch CJ, Feinberg LF, Stevens EJ. Predictors of institutionalization for persons with Alzheimer's disease and the impact on family caregivers. J Ment Health Aging. 1999; 5: 275-288.Google Scholar
  14. 14.
    Miller B, Cafasso L. Gender differences in caregiving: Fact or artifact? Gerontologist. 1992; 32: 498-507.PubMedCrossRefGoogle Scholar
  15. 15.
    Grad J, Sainsbury P. Mental illness and the family. Lancet. 1963; 1: 544-547.PubMedCrossRefGoogle Scholar
  16. 16.
    Schulz R, Sherwood PR. Physical and mental health effects of family caregiving. Am J Nurs. 2008; 108: 23-27. quiz 27.PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Vitaliano P, Echeverria D, Shelkey M, Zhang JP, Scanlan J. A cognitive psychophysiological model to predict functional decline in chronically stressed older adults. J Clin Psychol Med S. 2007; 14: 177-190.CrossRefGoogle Scholar
  18. 18.
    Mittelman MS. A family intervention to delay nursing home placement of patients with Alzheimer's disease. A randomized controlled trial. J Am Med Assoc. 1996; 276: 1725-1731.CrossRefGoogle Scholar
  19. 19.
    Zubin J, Spring B. Vulnerability—a new view of schizophrenia. J Abnorm Psychol. 1977; 86: 103-126.PubMedCrossRefGoogle Scholar
  20. 20.
    Vitaliano PP, Zhang J, Scanlan JM. Is caregiving hazardous to one's physical health? A meta-analysis. Psychol Bull. 2003; 129: 946-972.PubMedCrossRefGoogle Scholar
  21. 21.
    Russo J, Vitaliano PP, Brewer DD, Katon W, Becker J. Psychiatric disorders in spouse caregivers of care recipients with Alzheimer's disease and matched controls: A diathesis-stress model of psychopathology. J Abnorm Psychol. 1995; 104: 197-204.PubMedCrossRefGoogle Scholar
  22. 22.
    Little RJ, Rubin DB. Causal effects in clinical and epidemiological studies via potential outcomes: Concepts and analytical approaches. Annu Rev Publ Health. 2000; 21: 121-145.CrossRefGoogle Scholar
  23. 23.
    McGue M, Osler M, Christensen K. Causal inference and observational research: The utility of twins. Perspect Psychol Sci. 2010; 5: 546-556.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Rubin DB. For objective causal inference, design trumps analysis. Ann Appl Stat. 2008; 2: 808-840.CrossRefGoogle Scholar
  25. 25.
    Afari N, Noonan C, Goldberg J, et al. University of Washington Twin Registry: Construction and characteristics of a community-based twin registry. Twin Res Hum Genet. 2006; 9: 1023-1029.PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Strachan E, Hunt C, Afari N, et al. The University of Washington Twin Registry: Poised for the next generation of twin research. Twin Res Hum Genet. 2012; 1–8.Google Scholar
  27. 27.
    Kendler KS, Prescott CA. A population-based twin study of lifetime major depression in men and women. Arch Gen Psychiat. 1999; 56: 39-44.PubMedCrossRefGoogle Scholar
  28. 28.
    Kendler KS, Kessler RC, Walters EE, et al. Stressful life events, genetic liability, and onset of an episode of major depression in women. Am J Psychiat. 1995; 152: 833-842.PubMedGoogle Scholar
  29. 29.
    Federenko IS, Schlotz W, Kirschbaum C, Bartels M, Hellhammer DH, Wust S. The heritability of perceived stress. Psychol Med. 2006; 36: 375-385.PubMedCrossRefGoogle Scholar
  30. 30.
    Reed T, Plassman BL, Tanner CM, Dick DM, Rinehart SA, Nichols WC. Verification of self-report of zygosity determined via DNA testing in a subset of the NAS-NRC Twin Registry 40 years later. Twin Res Hum Genet. 2005; 8: 362-367.PubMedCentralPubMedCrossRefGoogle Scholar
  31. 31.
    Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Heal Soc Behav. 1983; 24: 385-396.CrossRefGoogle Scholar
  32. 32.
    Mitchell AM, Crane PA, Kim Y. Perceived stress in survivors of suicide: Psychometric properties of the perceived stress scale. Res Nurs Health. 2008; 31: 576-585.PubMedCrossRefGoogle Scholar
  33. 33.
    Lazarus RS, Folkman S. Stress, Appraisal, and Coping. New York: Springer Publishing Company; 1984.Google Scholar
  34. 34.
    Leventhal H, Brown D, Shacham S, Engquist G. Effects of preparatory information about sensations, threat of pain, and attention on cold pressor distress. J Pers Soc Psychol. 1979; 37: 688-714.PubMedCrossRefGoogle Scholar
  35. 35.
    Selye H. The Stress of Life. New York: McGraw-Hill; 1956.Google Scholar
  36. 36.
    Ware J, Kosinski M, Dewey J, Gandek B. A Manual for Users of the SF-8 Health Survey. Lincoln, RI: Quality Metrics Inc.; 2001.Google Scholar
  37. 37.
    Derogatis LR, Melisaratos N. The brief symptom inventory: An introductory report. Psychol Med. 1983; 13: 595-605.PubMedCrossRefGoogle Scholar
  38. 38.
    De Jong MM, An K, McKinley S, Garvin BJ, Hall LA, Moser DK. Using a 0–10 scale for assessment of anxiety in patients with acute myocardial infarction. Dimens Crit Care Nurs. 2005; 24: 139-146.PubMedCrossRefGoogle Scholar
  39. 39.
    Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Med Care. 2003; 41: 1284-1292.PubMedCrossRefGoogle Scholar
  40. 40.
    Daig I, Herschbach P, Lehmann A, Knoll N, Decker O. Gender and age differences in domain-specific life satisfaction and the impact of depressive and anxiety symptoms: A general population survey from Germany. Qual Life Res. 2009; 18: 669-678.PubMedCrossRefGoogle Scholar
  41. 41.
    Bergen SE, Kendler KS, Gardner CO, Aggen SH. Socioeconomic status and social support following illicit drug use: Causal pathways or common liability? Twin Res Hum Genet. 2008; 11: 266-274.PubMedCentralPubMedCrossRefGoogle Scholar
  42. 42.
    Vitaliano PP, Russo J, Young HM, Teri L, Maiuro RD. Predictors of burden in spouse caregivers of individuals with Alzheimer's disease. Psychol Aging. 1991; 6: 392-402.PubMedCrossRefGoogle Scholar
  43. 43.
    Monroe SM, Simmons AD. Diathesis-stress theories in the context of life stress research: Implications for the depressive disorders. Psychological Bulletin. 1991; 110: 406-425.PubMedCrossRefGoogle Scholar
  44. 44.
    Robins LN. Sturdy childhood predictors of adult antisocial behavior: Replications from longitudinal studies. Psychol Med. 1978; 8: 611-622.PubMedCrossRefGoogle Scholar
  45. 45.
    Adler NE, Coriell M. Socioeconomic status and health: Do we know what explains the association? Adv J Mind Body Health. 1995; 11: 6-9.Google Scholar
  46. 46.
    Adler N, Boyce T, Chesney M, et al. Socioeconomic status and health. The challenge of the gradient. Am Psychol. 1994; 49: 15-24.PubMedCrossRefGoogle Scholar
  47. 47.
    Regier DA. The linkage of health care reform and health services research. Am J Psychiat. 1993; 150: 1613-1615.PubMedGoogle Scholar
  48. 48.
    Bourdon K, Rae D, Narrow W, Manderschild R, Regier D. National prevalence and treatment of mental and addictive disorders. In: Mandershild R, Sonnenschein M, eds. Mental Health, United States, 1994. Washington, DC: Center for Mental Health Services; 1994: 22-51.Google Scholar
  49. 49.
    McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Affair. 2002; 21: 78-93.CrossRefGoogle Scholar
  50. 50.
    McGrath E, American Psychological Association National Task Force on Women and Depression. Women and Depression: Risk Factors and Treatment Issues: Final Report of the American Psychological Association's National Task Force on Women and Depression. Washington, DC: American Psychological Association; 1990.CrossRefGoogle Scholar
  51. 51.
    Conger RD, Wallace LE, Sun Y, Simons RL, McLoyd VC, Brody GH. Economic pressure in African-American families: A replication and extension of the family stress model. Dev Psychol. 2002; 38: 179-193.PubMedCrossRefGoogle Scholar
  52. 52.
    Conger RD, Conger KJ, Martin MJ. Socioeconomic status, family processes, and individual development. J Marriage Fam. 2010; 72: 685-704.PubMedCentralPubMedCrossRefGoogle Scholar
  53. 53.
    Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet. 1997; 349: 1436-1442.PubMedCrossRefGoogle Scholar
  54. 54.
    Kendler KS, Karkowski-Shuman L. Stressful life events and genetic liability to major depression: Genetic control of exposure to the environment? Psychol Med. 1997; 27: 539-547.PubMedCrossRefGoogle Scholar
  55. 55.
    Saudino KJ, Pedersen NL, Lichtenstein P, McClearn GE, Plomin R. Can personality explain genetic influences on life events? J Pers Soc Psychol. 1997; 72: 196-206.PubMedCrossRefGoogle Scholar
  56. 56.
    Hansell NK, Wright MJ, Medland SE, et al. Genetic comorbidity between neuroticism, anxiety/depression, and somatic distress in a population sample of adolescent and young adult twins. Psychol Med. 2012; 42: 1249-1260.PubMedCrossRefGoogle Scholar
  57. 57.
    Schulz R, Beach SR. Caregiving as a risk factor for mortality—The caregiver health effects study. J Amer Med Assoc. 1999; 282: 2215-2219.CrossRefGoogle Scholar
  58. 58.
    Vitaliano PP, Scanlan JM, Zhang J, Savage MV, Hirsch IB, Siegler IC. A path model of chronic stress, the metabolic syndrome, and coronary heart disease. Psychosom Med. 2002; 64: 418-435.PubMedGoogle Scholar
  59. 59.
    Vitaliano PP, Zhang J, Young HM, Caswell LW, Scanlan JM, Echeverria D. Depressed mood mediates decline in cognitive processing speed in caregivers. Gerontologist. 2009; 49: 12-22.PubMedCentralPubMedCrossRefGoogle Scholar
  60. 60.
    Vitaliano PP, Persson R, Kiyak A, Saini H, Echeverria D. Caregiving and gingival symptom reports: Psychophysiologic mediators. Psychosom Med. 2005; 67: 930-938.PubMedCrossRefGoogle Scholar
  61. 61.
    Kiecolt-Glaser JK, Glaser R, Gravenstein S, Malarkey WB, Sheridan J. Chronic stress alters the immune response to influenza virus vaccine in older adults. Proc Natl Acad Sci U S A. 1996; 93: 3043-3047.PubMedCentralPubMedCrossRefGoogle Scholar
  62. 62.
    Kiecolt-Glaser JK, Marucha PT, Malarkey WB, Mercado AM, Glaser R. Slowing of wound healing by psychological stress. Lancet. 1995; 346: 1194-1196.PubMedCrossRefGoogle Scholar

Copyright information

© The Society of Behavioral Medicine 2013

Authors and Affiliations

  • Peter P. Vitaliano
    • 1
  • Eric Strachan
    • 1
    • 5
  • Elizabeth Dansie
    • 2
  • Jack Goldberg
    • 3
    • 5
  • Dedra Buchwald
    • 3
    • 4
    • 5
    • 6
  1. 1.Department of Psychiatry and Behavioral SciencesUniversity of WashingtonSeattleUSA
  2. 2.Department of Anesthesiology and Pain MedicineUniversity of WashingtonSeattleUSA
  3. 3.Department of EpidemiologyUniversity of WashingtonSeattleUSA
  4. 4.Department of MedicineUniversity of WashingtonSeattleUSA
  5. 5.The University of Washington Twin RegistrySeattleUSA
  6. 6.Center for Clinical and Epidemiological ResearchUniversity of WashingtonSeattleUSA

Personalised recommendations