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Year : 2014  |  Volume : 139  |  Issue : 1  |  Page : 174-177

Assessment of stress & related albuminuria in caregivers of severe mentally ill persons

1 Medical College & Hospital, Kolkata, West Bengal, India
2 Department of Biochemistry, Malda Medical College & Hospital, Malda, West Bengal, India
3 Department of Biochemistry, Murshidabad Medical College, Berhampore, West Bengal, India

Date of Submission07-Jan-2013
Date of Web Publication6-Mar-2014

Correspondence Address:
Angshuman De
Anamika Flat No.6, P-68 South Park, PS + PO Bansdroni, Kolkata 700 070
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Source of Support: None, Conflict of Interest: None

PMID: 24604053

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Background & objectives: The family caregivers of patients with chronic diseases are known to undergo psychiatric stress leading to oxidative damage to glomerular membrane of kidney resulting in proteinuria. This study was aimed to compare current anxiety, depression levels and urinary albumin:creatinine ratio between primary caregivers of chronic mental patients and matched controls, and also whether the urinary albumin : creatinine ratio is correlated with stress factors (state and trait anxiety level, depression and caregiver burden) amongst caregivers.
Methods: The present cross-sectional study included 131 subjects (93 primary caregivers of patients with major mental illness as cases and 38 normal controls). They completed the Burden Assessment Schedule of SCARF, State Trait Anxiety Inventory and Beck's Depression Inventory. A spot urine sample was tested for urinary albumin : creatinine ratio from all study subjects.
Results: Mean values of current State and Trait anxiety, depression, urinary albumin:creatinine ratio were significantly higher in caregivers than controls (P < 0.001). Urinary albumin : creatinine ratio was significantly correlated (P < 0.001) with State and Trait anxiety level, depression as well as caregiver burden.
Interpretation & conclusions: The study demonstrated depression , anxiety and albuminuria amongst primary caregivers of patients with mental illness. Increase in the caregivers' burden, depression and anxiety resulted in an increase in the urinary albumin: creatinine ratio. This indicates that psychological stress is one of the determinants of albumin excretion rate in otherwise healthy subjects.

Keywords: Albuminuria - albumin : creatinine ratio - anxiety - depression - primary caregivers - schizophrenia

How to cite this article:
Dalui A, Guha P, De A, Chakraborty S, Chakraborty I. Assessment of stress & related albuminuria in caregivers of severe mentally ill persons. Indian J Med Res 2014;139:174-7

How to cite this URL:
Dalui A, Guha P, De A, Chakraborty S, Chakraborty I. Assessment of stress & related albuminuria in caregivers of severe mentally ill persons. Indian J Med Res [serial online] 2014 [cited 2020 Feb 23];139:174-7. Available from:

It has been reported that over 60 per cent of patients with major mental illness are supposed to live with at least one primary caregiver, the main provider of physical and emotional support for them [1] . The demands of caring for a chronic [2],[3],[4] and mentally ill relative have an emotional, social and practical stress on the caregivers [5],[6],[7],[8] leading to increase in glomerular membrane permeability of kidney [9],[10] and subsequently resulting in an increase in urinary albumin excretion. Several studies [11],[12],[13],[14] have been carried out to evaluate the relationship between stress and urinary albumin excretion. The present study was undertaken to compare the current anxiety and depression level, urinary albumin:creatinine ratio in the primary caregivers of patients with major mental illness with healthy controls, and to observe the relationship, if any, between stress factors (state and trait anxiety level, depression, caregiver burden) and urinary albumin:creatinine ratio among caregivers of patients with bipolar disorder and schizophrenia.

   Material & Methods Top

The present hospital based, cross-sectional study was undertaken between May to June 2010 in the Department of Psychiatry, Medical College and Hospital, Kolkata, India. The study protocol was approved by the Institutional Ethics Committee.

Primary caregivers of patients with major mental illness, attending the psychiatry department of Medical College, Kolkata, were selected by random sampling method. Along with the general health assessment, routine urine, haematological and biochemical examinations were done for both cases and controls to rule out diseases mentioned in exclusion criteria.

The primary caregiver was identified as an adult relative (age 16-60 yr man/woman) living with a patient, in the same environment for minimum six months, and felt most responsible for the patient. All subjects suffering from any inherited or acquired diseases leading to albuminuria like glomerulonephritis, glomerular disease of diabetes mellitus, systemic lupus erythematosus, amyloidosis, hypertension, infectious diseases like HIV, hepatitis, syphilis, malaria, severe mental illness or dementia, history of drug intake liable to cause albuminuria were excluded from the study.

Among the primary caregivers, 93 (45.56 ± 9.56 yr, 33 women) were selected as cases. Only thirty eight controls (46.81 ± 9.27 yr including 13 women) could be selected from apparently healthy age, sex, socio-economic status matched individuals (hospital staff, attendants of other patients) who did not have to bear a chronic caregiver burden and did not have other diseases or conditions, mentioned in exclusion criteria. The cases and controls were informed about the purpose of the study and written informed consent for inclusion in the study was obtained.

Primary caregivers were requested to give their response to the 'Primary Caregiver (PC) questionnaire'. It was a structured questionnaire proforma containing socio-demographic and care-giving details. After that, caregivers completed the Caregiver Burden Assessment Schedule (BAS) of SCARF (Schizophrenia Research Foundation) [15],[16] , validated Bengali version of State Trait Anxiety Inventory Form Y (STAI) [17],[18] and validated Bengali version of Beck's Depression Inventory (BDI) [19],[20] . A midstream and clean-catch spot urine sample was tested mainly in the morning (during Psychiatric Outdoor hours: 0900 - 1400 h) for urinary albumin:creatinine ratio [21] using ERBA IM Mannheim kits (Germany, India) for quantitative determination of urinary microalbumin and creatinine (Jaffe's method [22] . The same procedure was repeated for the control sample.

Statistical analysis: The data were analyzed using SPSS software version 14 for Windows (SPSS Inc., Chicago, USA). Statistically significant difference was determined by the Student's t test. Correlation cofficient was calculated according to the Brave-Pearson function. Regression analysis and Fisher exact test were used as statistical tool.

   Results Top

The socio-demographic pattern of caregivers and controls is shown in [Table 1]. The State anxiety level, Trait anxiety level, depression score and caregivers' burden were significantly higher in caregivers as compared to controls (P < 0.001) [Table 2]. Urinary albumin-creatinine ratio was also significantly higher in cases than in controls (P < 0.001). Of the 93 caregivers, 88 (94.6%) had microalbuminuria (30-300 mg/g of creatinine) and five (5.4%) had macroalbuminuria (>300 mg/g of creatinine). None of the caregivers was in the normal range (0-30 mg/g of creatinine) of urinary albumin-creatinine ratio, however, 10 of 38 controls (26.3%) were normal.
Table 1: Socio-demographic patterns of caregivers (cases) and controls

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Table 2: Correlation of UAl:Cr with BAS score, State and Trait anxiety level, and BDI score of caregivers

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Multiple regression analysis in caregivers showed that urinary albumin-creatinine ratio demonstrated a significant positive correlation with caregiver burden, current anxiety level and depression score (P < 0.001) [Table 3].
Table 3: Comparison of parameters between primary caregivers (Cases) and healthy individuals (Controls)

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   Discussion Top

This study showed that there was a raised level of depression, State and Trait anxiety level as well as caregivers burden in cases compared to control. Several other studies have reported similar findings [23],[24], [25] . The urinary albumin:creatinine ratio (UAl:Cr) was found to be significantly higher among the cases than controls as shown in earlier studies [11],[12],[13],[14] . In our study, none of the controls had macroalbuminuria. Though 73.7 per cent controls had microalbuminuria, but highest value was 56.14 mg/g which was on the lower side of microalbuminuria range (30-300 mg/g of creatinine) whereas 94.6 per cent of cases showed high microalbuminuria with highest value being 293 mg/g of creatinine. All biochemical reference values are known to vary depending on the type of population, race, ehnicity, which may be a reason for higher limit of urinary microalbumin in control population [26],[27],[28],[29] .

Multiple regression analysis in caregivers demonstrated a significant positive correlation between UAl:Cr ratio and caregiver burden, current anxiety level and depression. It was evident from the results that if there was an increase in the stress factors, there was obvious increase in the urinary albumin:creatinine ratio. This result can be explained by the fact that increased burden, depression and anxiety lead to increased physical oxidative stress that affects the renal system causing increased albuminuria. Ratnakar et al[9] have also shown that stress leads to increased glomerular permeability to proteins. As during screening, no causes of raised value of Alb:Cr ratio was noted, this difference between cases and controls could be ascribed to mental and social stress of caregivers. Though caregivers appear normal, but ongoing mental stress due to caregiving may generate physical stress of which albuminuria may be one early sign.

The limitations of the study was its small sample size; the number of controls was not equal to the cases. Being a short study, it was not possible to collect urine for three times on different days. So the physiological variations [high intra-individual CV (30-50%) and diurnal variation (50-100% higher during the day)] [29] could influence the albumin excretion in urine which should be kept in mind while planning for larger population study which may establish urinary albumin: creatinine ratio as a simple non-invasive screening test for primary caregiver burden assessment.

   Acknowledgment Top

The first author (AD) acknowledges the Indian Council of Medical Research, New Delhi, for providing Short Term Studentship.

   References Top

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  [Table 1], [Table 2], [Table 3]


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