Analysis of Rumination, Thought Suppression, and Coping Strategies Among Caregivers of Bipolar Disorder and  Alzheimer’s Dementia Patients

Analysis of Rumination, Thought Suppression, and Coping Strategies Among Caregivers of Bipolar Disorder and Alzheimer’s Dementia Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Analysis of Rumination, Thought Suppression, and Coping Strategies Among Caregivers of Bipolar Disorder and Alzheimer’s Dementia Patients Maliheh Riahi Ghahfarokhi, Zanireh Salimi, Alireza Zibaei, Reza bidaki This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6449239/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Objective Family caregivers of patients with bipolar disorder or dementia show high levels of psychological distress, partly explained by rumination and thought suppression—features that call for tailored interventions. The present study aims at comparing rumination, thought suppression, and coping strategies in caregivers of patients with bipolar disorder and Alzheimer's dementia to understand the unique psychological burdens borne by these groups. Methods 80 carers from Yazd, Iran, were recruited through targeted sampling at local health care facilities and community support groups and were divided into two equal groups caring for either a person with bipolar disorder (n = 40) or a person with dementia (n = 40). The data were collected by using the Hoeksma and Maro Rumination Questionnaire, the White Bear Suppression Inventory, and the Lazarus and Folkman Coping Strategies Questionnaire. Statistical analyses were conducted with independent t-tests using p < 0.05 as the significance level. Results Family caregivers of individuals with bipolar disorder reported significantly more rumination, thought suppression, and emotion-focused coping than dementia caregivers. Problem-focused coping did not differ significantly between the groups. Conclusion Our results underline the increased psychosocial burden borne by caregivers of bipolar patients, accounting for the episodic and unpredictable course of the disorder. Caregivers of dementia patients, experiencing through the progressive course of cognitive decline, present lower levels of rumination and thought suppression. Tailored interventions in problem-solving and emotional resilience need to consider the particular needs of each caregiver group. Caregivers Bipolar Disorder Alzheimer Disease Adaptation Psychological Stress Psychological 1 Introduction Caregiving for family members diagnosed with chronic mental health conditions, such as bipolar disorder and dementia, places strong psychological and emotional pressures on their family caregivers. Researchers consistently report significantly increased symptoms of depression and anxiety along with general psychological morbidity, which is in many cases, far greater than is found in the general population as well as when compared with caregiving for other illness conditions​( 1 – 3 ). The cognitive and emotional demands of caregiving, especially in the presence of unpredictable mood swings or cognitive decline, lead to chronic stress that can wear away at mental health​( 4 , 5 ). Rumination is conceptualized as a key factor in maintaining and exacerbating psychological symptoms in caregivers ( 1 , 6 ). This repetitive and passive focus on distressing thoughts has been linked to greater depressive and anxious symptoms in caregivers for persons with dementia, especially in combination with attentional biases toward negative information ( 1 ). Similarly, family caregivers of persons with bipolar disorder have also shown high levels of rumination, which correlates with more severe depressive symptoms and less adaptive coping strategies​( 6 , 7 ). Moreover, thought suppression—a deliberate attempt to avoid distressing thoughts—has been shown to increase the very thoughts it tries to suppress, often with the paradoxical effect of making the thoughts more intrusive ( 2 , 5 ). Understanding these cognitive and disorder patterns in caregivers of both dementia and bipolar patients is important for the development of targeted support interventions that mitigate these effects and promote healthier coping strategies( 1 , 3 , 6 ). 2 Methods 2.1 Target Population This study involved 80 family caregivers in Yazd, Iran. They equally comprised of family members taking care of patients with bipolar disorder (n = 40) and patients with dementia (n = 40). 2.2 Sampling Method Participants were recruited using targeted sampling at local health facilities and community support groups, ensuring active involvement in caregiving activities. 2.3 Measures Rumination Questionnaire The reliability of this questionnaire was supported by ( 8 ), who reported a Cronbach's alpha of 0.80nally, ( 9 ) found a Cronbach's alpha of 0.90 for the overall scale, with values of 0.92 and 0.89 for specific subscales. Its validity was demonstrated by a 0.65 correlation with metacognitive beliefs (p < 0.001), indicating strong criterion validity. White Bear Suppression Inventory (WBSI) Validated by ( 10 ) with a sample of 83 students, this scale achieved a concurrent validity correlation of r = 0.51 with the Beck Depression Inventory-II, and an internal consistency reliability of 0.78 (Cronbach’s alpha). Coping Strategies Questionnaire ( 11 ) reported a reliability of 0.80 using Cronbach’s alpha for internal consistency. Further, ( 12 ) confirmed the face validity of the questionnaire through expert review by three psychology specialists from Qom University, and reported an internal consistency reliability of 0.92 (Cronbach’s alpha). 2.4 Data Collection The participants were interviewed and administered standardized questionnaires in private sessions with trained researchers to minimize the chance of any mistake and distress to the participant. Each session consumed about one hour. 2.5 Statistical Analysis Data was analyzed using SPSS version 27. Independent t-tests were used to compare rumination, thought suppression, and coping strategies scores between the two groups of caregivers. A p-value of < 0.05 was considered statistically significant. 3 Results The analysis revealed that the two caregiver groups differed significantly concerning rumination, thought suppression, and coping strategies. All measured variables are presented in one table (Table 1 ) with mean scores, standard deviations, t-values, and p-values for all. 3.1 Rumination Caregivers for individuals with bipolar disorder scored significantly higher on rumination compared to the caregivers for individuals with dementia. The mean rumination score was 28.5 (SD = 5.2) for the bipolar group and 22.7 (SD = 4.9) for the dementia group. This difference was statistically significant, t = 3.24, p < 0.05. These results suggest that bipolar caregivers experience more repetitive and distressing thoughts. This is likely because of the difficulties of not knowing day to day what bipolar symptoms will be manifested. 3.2 Thought Suppression Thought suppression scores, measured by the White Bear Suppression Inventory (WBSI), were also higher among bipolar caregivers. Their mean thought suppression score was 25.3 (SD = 6.1), whereas the dementia group averaged 19.8 (SD = 5.5). This difference was statistically significant (t = 2.95, p < 0.05), indicating that bipolar caregivers may attempt to suppress intrusive thoughts more frequently—a strategy that can paradoxically lead to increased psychological distress. 3.3 Coping Strategies Coping Strategies. Bipolar caregivers had significantly higher ratings of emotion-focused coping (M = 30.1, SD = 5.4) compared to dementia caregivers (M = 24.6, SD = 5.0), a difference that was statistically significant (t = 3.12, p < 0.05). This could possibly be due to the reliance of bipolar caregivers on managing emotional responses to stressors, which may bring short-term relief but also contributes to overall long-term mental health challenges. No significant difference was found in problem-focused coping strategies between the two groups (t = 1.25, p > 0.05). Both groups reported similar levels of problem-focused coping, with mean scores of 26.8 (SD = 4.7) for bipolar caregivers and 27.3 (SD = 4.5) for dementia caregivers, indicating that both sets of caregivers try to actively engage in problem-solving strategies despite the different challenges they face. 3.4 Summary of Findings Overall, caregivers of patients with bipolar disorder had a higher level of rumination, thought suppression, and emotion-focused coping, while dementia caregivers scored relatively lower on these measures. The absence of a significant difference in problem-focused coping between the two groups implies that both groups of caregivers have similar problem-solving strategies, thus indicating an area where universal supportive interventions can be applied. Table 1 Comparison of Psychological Measures and Coping Strategies Between Bipolar and Dementia Caregivers Variable Bipolar Disorder Caregivers (Mean ± SD) Dementia Caregivers (Mean ± SD) t-value p-value Rumination 28.5 ± 5.2 22.7 ± 4.9 3.24 < 0.05 Thought Suppression 25.3 ± 6.1 19.8 ± 5.5 2.95 < 0.05 Emotion-Focused Coping 30.1 ± 5.4 24.6 ± 5.0 3.12 0.05 Note : Significant differences (p < 0.05) were observed in rumination, thought suppression, and emotion-focused coping, with bipolar caregivers reporting higher scores for these measures. No significant difference was found in problem-focused coping strategies. 4 Discussion This study provides a very significant psychological distinction between the caregivers of a patient with bipolar disorder and those with dementia. The findings show that caregivers of bipolar patients ruminate more, suppress thoughts more, and greatly rely on emotion-focused coping strategies than do dementia caregivers. These distinctions show that each disorder brings its unique challenges for caregiver mental health, social life, and coping mechanisms. Caregivers of bipolar disorder patients face unique and strong psychological burdens because mood episodes, particularly mania and depression, can never be predicted. Ogilvie, Morant, and Goodwin found in their study that caregivers are subject to profound emotional and social strain, increased by the potential for sudden behavioral changes in the person under their care( 13 ). This high emotional burden often results in increased utilization of mental health services among caregivers, as they seek support to manage stress-induced symptoms of depression and anxiety ( 14 ). This high emotional burden often results in increased utilization of mental health services among caregivers, as they seek support to manage stress-induced symptoms of depression and anxiety( 15 ). The higher levels of rumination and thought suppression found in bipolar caregivers in this study may suggest that the cyclical nature of bipolar disorder may contribute to repetitive, distressing thoughts, which may be exacerbated by the caregivers' constant vigilance for either manic or depressive episodes. The paradoxical effect of thought suppression, where attempts at avoiding distressing thoughts actually raise them, would also further aggravate the psychological load on the carers and make them even more susceptible to the risk of emotional exhaustion and depressive symptoms, as established in previous research( 2 , 3 ). The caregivers for patients with dementia are also overwhelmed but in a different manner. Studies such as that by ( 16 ) reveal that while dementia caregiving is physically demanding and emotionally stressful, the gradual progression of dementia enables caregivers to establish somewhat predictable routines due to the fact that cognitive and physical declines follow a recognizable trajectory( 16 ). However, caregivers for people with dementia report high levels of social and emotional burden as the patient's condition deteriorates, as the disease brings about social isolation, role overload, and grief associated with the patient's progressive loss of function and identity( 5 , 16 ). Although in this study the levels of rumination and thought suppression among the caregivers of dementia patients were lower compared to those for bipolar patients, the use of both problem-focused and emotion-focused coping strategies still indicates the balancing of the emotional impact of the caregiving experience with the pragmatic demands of caring. ( 16 ) argue that dementia caregiving involves long-term emotional adaptation to cognitive decline which is accompanied by increased caregiver depression and anxiety across time. This underscores the need for interventions that can address the chronic stress of dementia caregiving through social and community support. These findings are consistent with previous literature focusing on coping strategy use, suggesting that bipolar disorder caregivers could greatly benefit from problem-focused interventions targeted at learning the skills to cope effectively with the caregiving challenges that are so inherently unpredictable. Training caregivers on problem-solving skills and stress-reduction techniques should help them respond adaptively to mood fluctuations in family members, reducing the overdependence on emotion-focused strategies that bring quick relief in some instances but result in poor attenuation of long-term stress. On the other hand, dementia caregivers will be more served by support programs oriented toward chronic stress and the improvement of social connections, since isolation is a salient concern for this population.( 15 )and ( 17 ) suggest intervening with a focus on building resilience, which has been found efficacious in decreasing caregiver depression and increasing psychological flexibility ​( 15 ) due to mental health supports, such as counseling or therapy, may also enable dementia caregivers to cope with the chronic psychological burdens of their care role more effectively. Caregiver burden comparison among disorders: the literature suggests that both groups experience serious psychological pressure but for differing factors. From such analyses of caregiver burden across psychiatric and neurodegenerative conditions, those with subjective experience of burden have been said to occur when caregivers lack support or when the patient's symptoms are severe such as behavioral disturbances found in bipolar disorder or late stages of cognitive decline in dementias. Recent studies have pointed out that the needs of mental health service reported by family members of mental health patients are higher in comparison to those caring for neurodegenerative conditions, probably because of the acute stressors associated with managing unpredictable mental health symptoms( 6 , 16 , 18 ). These ( 14 ) require individualized interventions that take into account the disorder-specific stressors of each caregiver group. Resilience-building programs, like CBT for bipolar caregivers and support groups for dementia caregivers, could significantly influence improvements in caregiver well-being. Additionally, community-based interventions that offer caregivers greater access to mental health services could reduce aggregate psychological distress and improve coping outcomes. This study adds to the body of knowledge about how caregiving for chronic mental and neurodegenerative disorders uniquely impacts caregiver mental health and coping mechanisms. In this regard, the present research underlines the importance of providing tailored support services by exploring the distinct psychological burdens and coping needs of caregivers for bipolar disorder and dementia. Future research should consider investigating how combined therapeutic approaches, such as resilience training with cognitive-behavioral support, could benefit both groups. Also, the role of social support networks and mental health resources in alleviating caregiver burden across both diseases remains an open area requiring further investigation. The present research has given more insight into the different psychological challenges faced by caregivers of people with bipolar disorder and dementia, which in turn require targeted intervention to address the specific burdens experienced with each disorder. The results show that, compared to control caregivers, caregivers of patients with bipolar disorder are more prone to rumination and thought suppression and rely heavily on emotion-focused coping strategies, probably due to the unpredictable and episodic nature of bipolar symptoms. This style of coping may bring about temporary emotional relief but does not mitigate the long-term psychological stress associated with caregiving in bipolar disorder. As a consequence, bipolar caregivers stand a higher probability of being subjected to mental problems, including depression and anxiety, whereby there is an increased need to have mental services targeting this care group. Other caregivers, though, tend to face somewhat different challenges throughout the progression stages of the condition. While dementia can cause significant cognitive and functional decline, which itself can be emotionally and physically stressful, the gradual trajectory may allow some caregivers to establish routines for coping over time. However, a systematic review and meta-analysis of caregiver burden among carers of people with mental illness ( 19 ) stressed that dementia carers still suffer from significant psychological distress, such as grief, social isolation, and depression stemming from the loss of the patient's abilities and identity. Such results suggest that dementia carers would benefit most from interventions that reduce isolation and the long-term emotional effects of caregiving. The two caregiver groups express that the interventions vary according to the type of challenges each faces; hence, more structured interventions about mental health would help caregivers to strengthen their resilience and tolerate the episodic demands of caregiving by increasing problem-focused coping strategies and reducing rumination in the case of caregivers about individuals with bipolar disorder. Additionally, resilience-building programs, such as cognitive-behavioral therapy (CBT) and mindfulness-based stress reduction, may help this group adopt healthier coping mechanisms that counteract thought suppression and break the cycle of negative rumination. Support programs for dementia caregivers that build emotional resilience, provide social engagement opportunities, and foster community connections could be of great help. Such interventions might help alleviate chronic stress and social isolation, ultimately enabling dementia caregivers to cope with the continuous demands and emotional toll of caregiving. Adding resources such as grief counseling and peer support groups could also greatly help dementia caregivers learn how to cope with their mixed and compound emotions brought about by long-term caregiving and loss. The study has some limitations that need to be considered in the interpretation of the findings. First, targeted sampling confined to a single geographic location—that is, Yazd—may limit the generalizability of the findings to other populations. Second, the data was based on self-report measures that may be susceptible to response bias. Finally, the study did not control for the possible impact of socio-economic and cultural factors that might have given a more subtle understanding of group differences. Future research is thus encouraged to use longitudinal designs and more diverse sampling to address these limitations extensively. 5 Conclusion this study adds to the literature by distinguishing the unique psychological profiles of caregivers for bipolar disorder and dementia patients. It describes the required interventions to suit the specific emotional, cognitive, and social difficulties of each of these groups independently. Furthermore, future studies will involve developing and testing individualized support programs in terms of their ability to provide combined resilience training, stress management, and social networks for caregivers as a way of helping to improve caregiver well-being and quality of care to individuals afflicted with chronic mental and neurodegenerative disorders. Declarations Ethics approval and consent to participate This study was carried out under ethical approval from the Ethics Committee of Islamic Azad University, Yazd Branch, with the reference number IR.IAU.YAZD.REC.1403.057. All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All participants provided written informed consent before taking part in the study. They were fully informed about the purpose, procedures, potential risks, and benefits of the study, and participation was entirely voluntary. Consent for publication Not Applicable Availability of data and materials The datasets generated during the current study are not publicly available due to confidentiality agreements with participants but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding .No funding or financial support from any institution has been received for this research. This study was self-conducted without any external financial support. Authors' contributions Reza Bidaki conceptualized and designed the study, analyzed the data, and wrote the manuscript. Maliheh Riahi Ghahfarokhi conducted the data collection, contributed to drafting the manuscript, and revised it critically for important intellectual content. Zanireh Salimi assisted with the statistical analysis, provided critical revisions, and reviewed the manuscript. Alireza Zibaei contributed to the interpretation of results, reviewed the manuscript, and provided final approval of the manuscript version for submission. All authors reviewed and approved the final manuscript. Acknowledgement The authors would like to thank caregivers and patients participating in this study, whose experiences have been invaluable in helping us improve our understanding of caregiver burden. This work was done independently without any kind of financial or institutional support. It was part of the masters' thesis for attaining the Master of Clinical Psychology at Islamic Azad University, Yazd Branch, and was conducted at the at Islamic Azad University. References Greenaway A-M, Hwang F, Nasuto S, Ho A. Rumination in dementia and its relationship with depression, anxiety, and attentional biases. Neuropsychology, development, and cognition Section B. Aging Neuropsychol cognition. 2024;31:1–27. Lappalainen P, Keinonen K, Pakkala I, Lappalainen R, Nikander R. The role of thought suppression and psychological inflexibility in older family caregivers’ psychological symptoms and quality of life. J Context Behav Sci. 2021;20:129–36. Perlick DA, Gonzalez J, Michael L, Huth M, Culver J, Kaczynski R, et al. Rumination, gender, and depressive symptoms associated with caregiving strain in bipolar disorder. Acta Psychiatr Scand. 2012;126(5):356–62. Derakhshan A, Karbalaee Mohammad Meigouni A, Seirafi MR. Comparison of depression, anxiety, rumination, thought suppression and coping styles in spouses of schizophrenic patients and normal individuals. Appl Psychol. 2017;10(4):367–86. Miklowitz DJ, Alatiq Y, Geddes JR, Goodwin GM, Williams JM. Thought suppression in patients with bipolar disorder. J Abnorm Psychol. 2010;119(2):355–65. Silveira M Jr. Rumination in bipolar disorder: a systematic review. Brazilian J Psychiatry. 2015;37. Calvete E, Franco MAR, Oñate L, Alonso MS-I, Bermejo-Toro L. Trait mindfulness, rumination, and well-being in family caregivers of people with acquired brain injury. Clínica y Salud. 2021;32(2):71–7. Tabibzadeh F, Azar FS. The Effect of Cognitive-Behavioral Therapy on the Resilience and Obsessive Rumination among Multiple Sclerosis (MS) Patients. Middle East J Disabil Stud. 2017;7(1):45. Bagherinezhad M, Salehi Fadardi J, Tabatabayi SM. The relationship between rumination and depression in a sample of Iranian student. Res Clin Psychol Couns. 2010;11(1). Farrokhi H, Mostafapour V. Investigating factor structure, validity and reliability of the Persian form of Anxious Thoughts Inventory (AnTI), Thought Control Questionnaire (TCQ) and White Bear Suppression Inventory (WBSI) in the Clinical Population. J Analytical-Cognitive Psychol. 2018;9(33):19–31. Toghyani E, Yousefi R. Psychometric properties of Persian version of emotion awareness questionnair. Q Educational Meas. 2019;9(35):213–32. Hamzei A, Aghayousefi A. Model of Structural Equations of Marital Adjustment Based on Self- Differentiation and Cognitive Flexibility Mediated by Coping Strategies. J Health Promotion Manage. 2023;12(1):16–31. Ogilvie AD, Morant N, Goodwin GM. The burden on informal caregivers of people with bipolar disorder. Bipolar Disord. 2005;7(Suppl 1):25–32. Perlick DA, Hohenstein JM, Clarkin JF, Kaczynski R, Rosenheck RA. Use of mental health and primary care services by caregivers of patients with bipolar disorder: a preliminary study. Bipolar Disord. 2005;7(2):126–35. Mirhosseini S, Parsa FI, Gharehbaghi M, Minaei-Moghadam S, Basirinezhad MH, Ebrahimi H. Care burden and associated factors among caregivers of patients with bipolar type I disorder. BMC Prim Care. 2024;25(1):321. Akyol MA, Söylemez BA, Küçükgüçlü Ö. Effects of Early-and Late-Onset Alzheimer's Disease on Caregiver Burden. Turkish J Family Med Prim Care. 2023;17(1):79–86. Blake JA, Fields MJ, Bowen P, Ejem D, Clay OJ. Social Support Networks Among Black Caregivers of Persons With Memory Problems. J Gerontol Nurs. 2024;50(1):22–9. Muris P, Merckelbach H, Horselenberg R. Individual differences in thought suppression. The White Bear Suppression Inventory: Factor structure, reliability, validity and correlates. Behav Res Ther. 1996;34(5–6):501–13. Cham CQ, Ibrahim N, Siau CS, Kalaman CR, Ho MC, Yahya AN, et al. editors. Caregiver burden among caregivers of patients with mental illness: A systematic review and meta-analysis. Healthcare: MDPI; 2022. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 29 Jun, 2025 Reviewers agreed at journal 25 Jun, 2025 Reviewers agreed at journal 21 Jun, 2025 Reviewers invited by journal 13 Jun, 2025 Editor assigned by journal 11 Jun, 2025 Editor invited by journal 20 May, 2025 Submission checks completed at journal 19 May, 2025 First submitted to journal 19 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6449239","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":471432610,"identity":"0c59957a-3258-433f-86d9-e6e6e69d1af2","order_by":0,"name":"Maliheh Riahi Ghahfarokhi","email":"","orcid":"","institution":"Islamic Azad University, Yazd","correspondingAuthor":false,"prefix":"","firstName":"Maliheh","middleName":"Riahi","lastName":"Ghahfarokhi","suffix":""},{"id":471432611,"identity":"9395ce4b-3b4d-4a1d-93cd-b05e5bc26c58","order_by":1,"name":"Zanireh Salimi","email":"","orcid":"","institution":"Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Zanireh","middleName":"","lastName":"Salimi","suffix":""},{"id":471432612,"identity":"b1635e98-dd6b-4af6-bdae-8cffa03261df","order_by":2,"name":"Alireza Zibaei","email":"","orcid":"","institution":"Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Alireza","middleName":"","lastName":"Zibaei","suffix":""},{"id":471432613,"identity":"25c4f60f-ff1b-4fcd-9f31-702993553817","order_by":3,"name":"Reza bidaki","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYBAC+wYgwdggwdjAw9j4gIHhAGEtBgcQWpoNSNECRDwMbBLEaTne/vAD4w4L2f6ew23VPDV35PgZmB8+uoFHi33PgWQJxjMSxjPONrbd5jn2zFiygc3YOAePFjuJhAMSjG0SiQ3nGYFa2A4nbjjAwyaNT4ux/MPmHyAt84Fainn+EaHFcAYzG9iWDUCHMfO2EaHF4EwamwXILxvPHGyWnNt32FiymYBfDI4ff3yDcUed7Lwz6Q8/vPl2WI6fvfnhY3xaQID5D5TBxAPmElCOAhh/kKJ6FIyCUTAKRgwAALEOU8F83XzqAAAAAElFTkSuQmCC","orcid":"","institution":"Research Center of Addiction and Behavioral Sciences, Shahid Sadoughi University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Reza","middleName":"","lastName":"bidaki","suffix":""}],"badges":[],"createdAt":"2025-04-14 21:53:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6449239/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6449239/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84698191,"identity":"b971eabd-b83b-4cd8-9fbf-df2db4c02ab8","added_by":"auto","created_at":"2025-06-16 10:58:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":600073,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6449239/v1/65f8bc3d-06fc-463c-998f-f2ef020c7fa7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Analysis of Rumination, Thought Suppression, and Coping Strategies Among Caregivers of Bipolar Disorder and Alzheimer’s Dementia Patients","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eCaregiving for family members diagnosed with chronic mental health conditions, such as bipolar disorder and dementia, places strong psychological and emotional pressures on their family caregivers. Researchers consistently report significantly increased symptoms of depression and anxiety along with general psychological morbidity, which is in many cases, far greater than is found in the general population as well as when compared with caregiving for other illness conditions​(\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The cognitive and emotional demands of caregiving, especially in the presence of unpredictable mood swings or cognitive decline, lead to chronic stress that can wear away at mental health​(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRumination is conceptualized as a key factor in maintaining and exacerbating psychological symptoms in caregivers (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This repetitive and passive focus on distressing thoughts has been linked to greater depressive and anxious symptoms in caregivers for persons with dementia, especially in combination with attentional biases toward negative information (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Similarly, family caregivers of persons with bipolar disorder have also shown high levels of rumination, which correlates with more severe depressive symptoms and less adaptive coping strategies​(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoreover, thought suppression\u0026mdash;a deliberate attempt to avoid distressing thoughts\u0026mdash;has been shown to increase the very thoughts it tries to suppress, often with the paradoxical effect of making the thoughts more intrusive (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Understanding these cognitive and disorder patterns in caregivers of both dementia and bipolar patients is important for the development of targeted support interventions that mitigate these effects and promote healthier coping strategies(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Target Population\u003c/h2\u003e \u003cp\u003eThis study involved 80 family caregivers in Yazd, Iran. They equally comprised of family members taking care of patients with bipolar disorder (n\u0026thinsp;=\u0026thinsp;40) and patients with dementia (n\u0026thinsp;=\u0026thinsp;40).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Sampling Method\u003c/h2\u003e \u003cp\u003eParticipants were recruited using targeted sampling at local health facilities and community support groups, ensuring active involvement in caregiving activities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Measures\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eRumination Questionnaire\u003c/strong\u003e \u003cp\u003eThe reliability of this questionnaire was supported by (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), who reported a Cronbach's alpha of 0.80nally, (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) found a Cronbach's alpha of 0.90 for the overall scale, with values of 0.92 and 0.89 for specific subscales. Its validity was demonstrated by a 0.65 correlation with metacognitive beliefs (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating strong criterion validity.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eWhite Bear Suppression Inventory (WBSI)\u003c/strong\u003e \u003cp\u003eValidated by (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) with a sample of 83 students, this scale achieved a concurrent validity correlation of r\u0026thinsp;=\u0026thinsp;0.51 with the Beck Depression Inventory-II, and an internal consistency reliability of 0.78 (Cronbach\u0026rsquo;s alpha).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCoping Strategies Questionnaire\u003c/strong\u003e \u003cp\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) reported a reliability of 0.80 using Cronbach\u0026rsquo;s alpha for internal consistency. Further, (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) confirmed the face validity of the questionnaire through expert review by three psychology specialists from Qom University, and reported an internal consistency reliability of 0.92 (Cronbach\u0026rsquo;s alpha).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Collection\u003c/h2\u003e \u003cp\u003eThe participants were interviewed and administered standardized questionnaires in private sessions with trained researchers to minimize the chance of any mistake and distress to the participant. Each session consumed about one hour.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical Analysis\u003c/h2\u003e \u003cp\u003eData was analyzed using SPSS version 27. Independent t-tests were used to compare rumination, thought suppression, and coping strategies scores between the two groups of caregivers. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe analysis revealed that the two caregiver groups differed significantly concerning rumination, thought suppression, and coping strategies. All measured variables are presented in one table (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) with mean scores, standard deviations, t-values, and p-values for all.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Rumination\u003c/h2\u003e \u003cp\u003eCaregivers for individuals with bipolar disorder scored significantly higher on rumination compared to the caregivers for individuals with dementia. The mean rumination score was 28.5 (SD\u0026thinsp;=\u0026thinsp;5.2) for the bipolar group and 22.7 (SD\u0026thinsp;=\u0026thinsp;4.9) for the dementia group. This difference was statistically significant, t\u0026thinsp;=\u0026thinsp;3.24, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. These results suggest that bipolar caregivers experience more repetitive and distressing thoughts. This is likely because of the difficulties of not knowing day to day what bipolar symptoms will be manifested.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Thought Suppression\u003c/h2\u003e \u003cp\u003eThought suppression scores, measured by the White Bear Suppression Inventory (WBSI), were also higher among bipolar caregivers. Their mean thought suppression score was 25.3 (SD\u0026thinsp;=\u0026thinsp;6.1), whereas the dementia group averaged 19.8 (SD\u0026thinsp;=\u0026thinsp;5.5). This difference was statistically significant (t\u0026thinsp;=\u0026thinsp;2.95, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), indicating that bipolar caregivers may attempt to suppress intrusive thoughts more frequently\u0026mdash;a strategy that can paradoxically lead to increased psychological distress.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Coping Strategies\u003c/h2\u003e \u003cp\u003eCoping Strategies. Bipolar caregivers had significantly higher ratings of emotion-focused coping (M\u0026thinsp;=\u0026thinsp;30.1, SD\u0026thinsp;=\u0026thinsp;5.4) compared to dementia caregivers (M\u0026thinsp;=\u0026thinsp;24.6, SD\u0026thinsp;=\u0026thinsp;5.0), a difference that was statistically significant (t\u0026thinsp;=\u0026thinsp;3.12, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This could possibly be due to the reliance of bipolar caregivers on managing emotional responses to stressors, which may bring short-term relief but also contributes to overall long-term mental health challenges.\u003c/p\u003e \u003cp\u003eNo significant difference was found in problem-focused coping strategies between the two groups (t\u0026thinsp;=\u0026thinsp;1.25, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Both groups reported similar levels of problem-focused coping, with mean scores of 26.8 (SD\u0026thinsp;=\u0026thinsp;4.7) for bipolar caregivers and 27.3 (SD\u0026thinsp;=\u0026thinsp;4.5) for dementia caregivers, indicating that both sets of caregivers try to actively engage in problem-solving strategies despite the different challenges they face.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Summary of Findings\u003c/h2\u003e \u003cp\u003eOverall, caregivers of patients with bipolar disorder had a higher level of rumination, thought suppression, and emotion-focused coping, while dementia caregivers scored relatively lower on these measures. The absence of a significant difference in problem-focused coping between the two groups implies that both groups of caregivers have similar problem-solving strategies, thus indicating an area where universal supportive interventions can be applied.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Psychological Measures and Coping Strategies Between Bipolar and Dementia Caregivers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBipolar Disorder Caregivers (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDementia Caregivers (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRumination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e28.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e22.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThought Suppression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e25.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e19.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotion-Focused Coping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e30.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e24.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProblem-Focused Coping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e26.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e27.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eNote\u003c/b\u003e: Significant differences (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were observed in rumination, thought suppression, and emotion-focused coping, with bipolar caregivers reporting higher scores for these measures. No significant difference was found in problem-focused coping strategies.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis study provides a very significant psychological distinction between the caregivers of a patient with bipolar disorder and those with dementia. The findings show that caregivers of bipolar patients ruminate more, suppress thoughts more, and greatly rely on emotion-focused coping strategies than do dementia caregivers. These distinctions show that each disorder brings its unique challenges for caregiver mental health, social life, and coping mechanisms.\u003c/p\u003e \u003cp\u003eCaregivers of bipolar disorder patients face unique and strong psychological burdens because mood episodes, particularly mania and depression, can never be predicted. Ogilvie, Morant, and Goodwin found in their study that caregivers are subject to profound emotional and social strain, increased by the potential for sudden behavioral changes in the person under their care(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This high emotional burden often results in increased utilization of mental health services among caregivers, as they seek support to manage stress-induced symptoms of depression and anxiety (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This high emotional burden often results in increased utilization of mental health services among caregivers, as they seek support to manage stress-induced symptoms of depression and anxiety(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe higher levels of rumination and thought suppression found in bipolar caregivers in this study may suggest that the cyclical nature of bipolar disorder may contribute to repetitive, distressing thoughts, which may be exacerbated by the caregivers' constant vigilance for either manic or depressive episodes. The paradoxical effect of thought suppression, where attempts at avoiding distressing thoughts actually raise them, would also further aggravate the psychological load on the carers and make them even more susceptible to the risk of emotional exhaustion and depressive symptoms, as established in previous research(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe caregivers for patients with dementia are also overwhelmed but in a different manner. Studies such as that by (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) reveal that while dementia caregiving is physically demanding and emotionally stressful, the gradual progression of dementia enables caregivers to establish somewhat predictable routines due to the fact that cognitive and physical declines follow a recognizable trajectory(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, caregivers for people with dementia report high levels of social and emotional burden as the patient's condition deteriorates, as the disease brings about social isolation, role overload, and grief associated with the patient's progressive loss of function and identity(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough in this study the levels of rumination and thought suppression among the caregivers of dementia patients were lower compared to those for bipolar patients, the use of both problem-focused and emotion-focused coping strategies still indicates the balancing of the emotional impact of the caregiving experience with the pragmatic demands of caring. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) argue that dementia caregiving involves long-term emotional adaptation to cognitive decline which is accompanied by increased caregiver depression and anxiety across time. This underscores the need for interventions that can address the chronic stress of dementia caregiving through social and community support.\u003c/p\u003e \u003cp\u003eThese findings are consistent with previous literature focusing on coping strategy use, suggesting that bipolar disorder caregivers could greatly benefit from problem-focused interventions targeted at learning the skills to cope effectively with the caregiving challenges that are so inherently unpredictable. Training caregivers on problem-solving skills and stress-reduction techniques should help them respond adaptively to mood fluctuations in family members, reducing the overdependence on emotion-focused strategies that bring quick relief in some instances but result in poor attenuation of long-term stress.\u003c/p\u003e \u003cp\u003eOn the other hand, dementia caregivers will be more served by support programs oriented toward chronic stress and the improvement of social connections, since isolation is a salient concern for this population.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)and (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) suggest intervening with a focus on building resilience, which has been found efficacious in decreasing caregiver depression and increasing psychological flexibility ​(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) due to mental health supports, such as counseling or therapy, may also enable dementia caregivers to cope with the chronic psychological burdens of their care role more effectively.\u003c/p\u003e \u003cp\u003eCaregiver burden comparison among disorders: the literature suggests that both groups experience serious psychological pressure but for differing factors. From such analyses of caregiver burden across psychiatric and neurodegenerative conditions, those with subjective experience of burden have been said to occur when caregivers lack support or when the patient's symptoms are severe such as behavioral disturbances found in bipolar disorder or late stages of cognitive decline in dementias. Recent studies have pointed out that the needs of mental health service reported by family members of mental health patients are higher in comparison to those caring for neurodegenerative conditions, probably because of the acute stressors associated with managing unpredictable mental health symptoms(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThese (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) require individualized interventions that take into account the disorder-specific stressors of each caregiver group. Resilience-building programs, like CBT for bipolar caregivers and support groups for dementia caregivers, could significantly influence improvements in caregiver well-being. Additionally, community-based interventions that offer caregivers greater access to mental health services could reduce aggregate psychological distress and improve coping outcomes.\u003c/p\u003e \u003cp\u003eThis study adds to the body of knowledge about how caregiving for chronic mental and neurodegenerative disorders uniquely impacts caregiver mental health and coping mechanisms. In this regard, the present research underlines the importance of providing tailored support services by exploring the distinct psychological burdens and coping needs of caregivers for bipolar disorder and dementia. Future research should consider investigating how combined therapeutic approaches, such as resilience training with cognitive-behavioral support, could benefit both groups. Also, the role of social support networks and mental health resources in alleviating caregiver burden across both diseases remains an open area requiring further investigation.\u003c/p\u003e \u003cp\u003eThe present research has given more insight into the different psychological challenges faced by caregivers of people with bipolar disorder and dementia, which in turn require targeted intervention to address the specific burdens experienced with each disorder. The results show that, compared to control caregivers, caregivers of patients with bipolar disorder are more prone to rumination and thought suppression and rely heavily on emotion-focused coping strategies, probably due to the unpredictable and episodic nature of bipolar symptoms. This style of coping may bring about temporary emotional relief but does not mitigate the long-term psychological stress associated with caregiving in bipolar disorder. As a consequence, bipolar caregivers stand a higher probability of being subjected to mental problems, including depression and anxiety, whereby there is an increased need to have mental services targeting this care group.\u003c/p\u003e \u003cp\u003eOther caregivers, though, tend to face somewhat different challenges throughout the progression stages of the condition. While dementia can cause significant cognitive and functional decline, which itself can be emotionally and physically stressful, the gradual trajectory may allow some caregivers to establish routines for coping over time. However, a systematic review and meta-analysis of caregiver burden among carers of people with mental illness (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) stressed that dementia carers still suffer from significant psychological distress, such as grief, social isolation, and depression stemming from the loss of the patient's abilities and identity. Such results suggest that dementia carers would benefit most from interventions that reduce isolation and the long-term emotional effects of caregiving.\u003c/p\u003e \u003cp\u003eThe two caregiver groups express that the interventions vary according to the type of challenges each faces; hence, more structured interventions about mental health would help caregivers to strengthen their resilience and tolerate the episodic demands of caregiving by increasing problem-focused coping strategies and reducing rumination in the case of caregivers about individuals with bipolar disorder. Additionally, resilience-building programs, such as cognitive-behavioral therapy (CBT) and mindfulness-based stress reduction, may help this group adopt healthier coping mechanisms that counteract thought suppression and break the cycle of negative rumination.\u003c/p\u003e \u003cp\u003eSupport programs for dementia caregivers that build emotional resilience, provide social engagement opportunities, and foster community connections could be of great help. Such interventions might help alleviate chronic stress and social isolation, ultimately enabling dementia caregivers to cope with the continuous demands and emotional toll of caregiving. Adding resources such as grief counseling and peer support groups could also greatly help dementia caregivers learn how to cope with their mixed and compound emotions brought about by long-term caregiving and loss.\u003c/p\u003e \u003cp\u003eThe study has some limitations that need to be considered in the interpretation of the findings. First, targeted sampling confined to a single geographic location\u0026mdash;that is, Yazd\u0026mdash;may limit the generalizability of the findings to other populations. Second, the data was based on self-report measures that may be susceptible to response bias. Finally, the study did not control for the possible impact of socio-economic and cultural factors that might have given a more subtle understanding of group differences. Future research is thus encouraged to use longitudinal designs and more diverse sampling to address these limitations extensively.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003ethis study adds to the literature by distinguishing the unique psychological profiles of caregivers for bipolar disorder and dementia patients. It describes the required interventions to suit the specific emotional, cognitive, and social difficulties of each of these groups independently. Furthermore, future studies will involve developing and testing individualized support programs in terms of their ability to provide combined resilience training, stress management, and social networks for caregivers as a way of helping to improve caregiver well-being and quality of care to individuals afflicted with chronic mental and neurodegenerative disorders.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u0026nbsp; Ethics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was carried out under ethical approval from the Ethics Committee of Islamic Azad University, Yazd Branch, with the reference number IR.IAU.YAZD.REC.1403.057. All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All participants provided written informed consent before taking part in the study. They were fully informed about the purpose, procedures, potential risks, and benefits of the study, and participation was entirely voluntary.\u003c/p\u003e\n\u003ch2\u003e\u0026nbsp; \u0026nbsp; Consent for publication\u003c/h2\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003ch2\u003e\u0026nbsp; \u0026nbsp; Availability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated during the current study are not publicly available due to confidentiality agreements with participants but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003e\u0026nbsp; \u0026nbsp; Competing\u0026nbsp;interests\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003e\u0026nbsp; \u0026nbsp; Funding\u003c/h2\u003e\n\u003cp\u003e.No funding or financial support from any institution has been received for this research. This study was self-conducted without any external financial support.\u003c/p\u003e\n\u003ch2\u003e\u0026nbsp; \u0026nbsp; Authors' contributions\u003c/h2\u003e\n\u003cp\u003eReza Bidaki conceptualized and designed the study, analyzed the data, and wrote the manuscript. Maliheh Riahi Ghahfarokhi conducted the data collection, contributed to drafting the manuscript, and revised it critically for important intellectual content. Zanireh Salimi assisted with the statistical analysis, provided critical revisions, and reviewed the manuscript. Alireza Zibaei contributed to the interpretation of results, reviewed the manuscript, and provided final approval of the manuscript version for submission. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003e\u0026nbsp; \u0026nbsp; Acknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors would like to thank caregivers and patients participating in this study, whose experiences have been invaluable in helping us improve our understanding of caregiver burden. This work was done independently without any kind of financial or institutional support. It was part of the masters' thesis for attaining the Master of Clinical Psychology at Islamic Azad University, Yazd Branch, and was conducted at the at Islamic Azad University.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGreenaway A-M, Hwang F, Nasuto S, Ho A. Rumination in dementia and its relationship with depression, anxiety, and attentional biases. Neuropsychology, development, and cognition Section B. Aging Neuropsychol cognition. 2024;31:1\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLappalainen P, Keinonen K, Pakkala I, Lappalainen R, Nikander R. The role of thought suppression and psychological inflexibility in older family caregivers\u0026rsquo; psychological symptoms and quality of life. J Context Behav Sci. 2021;20:129\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerlick DA, Gonzalez J, Michael L, Huth M, Culver J, Kaczynski R, et al. Rumination, gender, and depressive symptoms associated with caregiving strain in bipolar disorder. Acta Psychiatr Scand. 2012;126(5):356\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDerakhshan A, Karbalaee Mohammad Meigouni A, Seirafi MR. Comparison of depression, anxiety, rumination, thought suppression and coping styles in spouses of schizophrenic patients and normal individuals. Appl Psychol. 2017;10(4):367\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiklowitz DJ, Alatiq Y, Geddes JR, Goodwin GM, Williams JM. Thought suppression in patients with bipolar disorder. J Abnorm Psychol. 2010;119(2):355\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilveira M Jr. Rumination in bipolar disorder: a systematic review. Brazilian J Psychiatry. 2015;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCalvete E, Franco MAR, O\u0026ntilde;ate L, Alonso MS-I, Bermejo-Toro L. Trait mindfulness, rumination, and well-being in family caregivers of people with acquired brain injury. Cl\u0026iacute;nica y Salud. 2021;32(2):71\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTabibzadeh F, Azar FS. The Effect of Cognitive-Behavioral Therapy on the Resilience and Obsessive Rumination among Multiple Sclerosis (MS) Patients. Middle East J Disabil Stud. 2017;7(1):45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBagherinezhad M, Salehi Fadardi J, Tabatabayi SM. The relationship between rumination and depression in a sample of Iranian student. Res Clin Psychol Couns. 2010;11(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarrokhi H, Mostafapour V. Investigating factor structure, validity and reliability of the Persian form of Anxious Thoughts Inventory (AnTI), Thought Control Questionnaire (TCQ) and White Bear Suppression Inventory (WBSI) in the Clinical Population. J Analytical-Cognitive Psychol. 2018;9(33):19\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToghyani E, Yousefi R. Psychometric properties of Persian version of emotion awareness questionnair. Q Educational Meas. 2019;9(35):213\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamzei A, Aghayousefi A. Model of Structural Equations of Marital Adjustment Based on Self- Differentiation and Cognitive Flexibility Mediated by Coping Strategies. J Health Promotion Manage. 2023;12(1):16\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgilvie AD, Morant N, Goodwin GM. The burden on informal caregivers of people with bipolar disorder. Bipolar Disord. 2005;7(Suppl 1):25\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerlick DA, Hohenstein JM, Clarkin JF, Kaczynski R, Rosenheck RA. Use of mental health and primary care services by caregivers of patients with bipolar disorder: a preliminary study. Bipolar Disord. 2005;7(2):126\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMirhosseini S, Parsa FI, Gharehbaghi M, Minaei-Moghadam S, Basirinezhad MH, Ebrahimi H. Care burden and associated factors among caregivers of patients with bipolar type I disorder. BMC Prim Care. 2024;25(1):321.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkyol MA, S\u0026ouml;ylemez BA, K\u0026uuml;\u0026ccedil;\u0026uuml;kg\u0026uuml;\u0026ccedil;l\u0026uuml; \u0026Ouml;. Effects of Early-and Late-Onset Alzheimer's Disease on Caregiver Burden. Turkish J Family Med Prim Care. 2023;17(1):79\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlake JA, Fields MJ, Bowen P, Ejem D, Clay OJ. Social Support Networks Among Black Caregivers of Persons With Memory Problems. J Gerontol Nurs. 2024;50(1):22\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuris P, Merckelbach H, Horselenberg R. Individual differences in thought suppression. The White Bear Suppression Inventory: Factor structure, reliability, validity and correlates. Behav Res Ther. 1996;34(5\u0026ndash;6):501\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCham CQ, Ibrahim N, Siau CS, Kalaman CR, Ho MC, Yahya AN, et al. editors. Caregiver burden among caregivers of patients with mental illness: A systematic review and meta-analysis. Healthcare: MDPI; 2022.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Caregivers, Bipolar Disorder, Alzheimer Disease, Adaptation, Psychological, Stress, Psychological","lastPublishedDoi":"10.21203/rs.3.rs-6449239/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6449239/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eFamily caregivers of patients with bipolar disorder or dementia show high levels of psychological distress, partly explained by rumination and thought suppression\u0026mdash;features that call for tailored interventions. The present study aims at comparing rumination, thought suppression, and coping strategies in caregivers of patients with bipolar disorder and Alzheimer's dementia to understand the unique psychological burdens borne by these groups.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e80 carers from Yazd, Iran, were recruited through targeted sampling at local health care facilities and community support groups and were divided into two equal groups caring for either a person with bipolar disorder (n\u0026thinsp;=\u0026thinsp;40) or a person with dementia (n\u0026thinsp;=\u0026thinsp;40). The data were collected by using the Hoeksma and Maro Rumination Questionnaire, the White Bear Suppression Inventory, and the Lazarus and Folkman Coping Strategies Questionnaire. Statistical analyses were conducted with independent t-tests using p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 as the significance level.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFamily caregivers of individuals with bipolar disorder reported significantly more rumination, thought suppression, and emotion-focused coping than dementia caregivers. Problem-focused coping did not differ significantly between the groups.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur results underline the increased psychosocial burden borne by caregivers of bipolar patients, accounting for the episodic and unpredictable course of the disorder. Caregivers of dementia patients, experiencing through the progressive course of cognitive decline, present lower levels of rumination and thought suppression. Tailored interventions in problem-solving and emotional resilience need to consider the particular needs of each caregiver group.\u003c/p\u003e","manuscriptTitle":"Analysis of Rumination, Thought Suppression, and Coping Strategies Among Caregivers of Bipolar Disorder and Alzheimer’s Dementia Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-16 10:42:37","doi":"10.21203/rs.3.rs-6449239/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-06-29T16:52:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"141732225345300435226568163091622274311","date":"2025-06-25T10:59:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254077024975507573540355758719831425485","date":"2025-06-21T14:01:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-13T07:07:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-11T13:32:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-20T06:42:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-19T20:01:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2025-05-19T20:00:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"02d7ca8f-897e-467e-827d-877f261a873e","owner":[],"postedDate":"June 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-16T10:42:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-16 10:42:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6449239","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6449239","identity":"rs-6449239","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}